[MedRec]
[surgical operation]
[chemotherapy]
[diarrhea]
The patient started FOLFIRI treatment on 2023-08-22 and experienced significant diarrhea, with seven or more bowel movements per day.
Irinotecan, a component of FOLFIRI, can lead to both early and late-stage diarrhea. For early-stage diarrhea, which may come with cholinergic symptoms, atropine can be effective. Although a 0.25mg dose of atropine was initially used, increasing the dose to 0.5mg during the next treatment could be considered (can be up to 1mg). Late-stage diarrhea requires immediate attention with loperamide, as it could be life-threatening.
In cases of diarrhea, maintain close monitoring of fluid and electrolyte levels, and provide necessary supplementation. If complications like ileus, fever, or severe neutropenia arise, antibiotics may be needed. In the event of severe diarrhea, consider interrupting the irinotecan treatment and adjusting the dosage for subsequent administrations.
Patients who are homozygous for the UGT1A128 or 6 alleles (28/28, 6/6), or compound heterozygous UGT1A128 and 6 alleles (6/28), may require a dose reduction in the starting irinotecan level. Any future adjustments should be tailored to individual tolerance levels.
For treating diarrhea induced by cancer therapy, the initial oral dose of loperamide is 4 mg, followed by 2 mg every 2 to 4 hours or after each instance of loose stool. If diarrhea continues for more than 24 hours, the dose should be 2 mg every 2 hours, or alternatively, 4 mg every 4 hours. Continue this regimen until 12 hours have elapsed without a loose bowel movement, as per guidelines from Andreyev 2014, Benson 2004, and Sharma 2005. It’s worth noting that daily doses exceeding 16 mg may not offer additional benefit, and alternative treatments should be considered if diarrhea persists for 48 hours or more.
[leukopenia]
Around the third week following the patient’s initial FOLFIRI treatment, leukopenia was detected. However, after administering a dose of G-CSF (filgrastim 150ug) on 2023-09-11, no further instances of leukopenia have been observed as of now.
2023-09-12 WBC 4.70 x10^3/uL
2023-09-11 WBC 1.58 x10^3/uL
2023-09-08 WBC 1.81 x10^3/uL
2023-09-05 WBC 1.95 x10^3/uL
2023-08-22 WBC 4.85 x10^3/uL
[exam findings]
[MedRec]
[chemotherapy]
2023-09-11 FOLFOX
2023-08-16 FOLFOX
2023-07-28 FOLFOX
2023-07-12 FOLFOX
2023-06-26 FOLFOX
2023-06-05 FOLFOX
2023-05-08 FOLFOX
2023-04-10 FOLFOX
2023-03-21 FOLFOX
2023-03-03 FOLFOX
2023-02-16 FOLFOX
2023-01-16 5-FU
2023-01-09 5-FU
2022-12-30 5-FU
2022-12-28 5-FU
The medications in the repeat prescription provided by VGHTPE on 2023-08-09 were replenished on 2023-09-04 and are currently in use. No issues with medication reconciliation have been identified.
This patient obtained a 28-day refill of aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine, and atorvastatin from VGHTPE on 2023-08-09. All these medications are actively being used, and there are no discrepancies identified.
This patient refilled a prescription on 2023-07-03 that was issued by VGHTPE on 2023-05-10 for aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine and atorvastatin. These drugs are now on the active formulary with no reconciliation issues identified.
[exam findings]
[MedRec]
[consultation]
[chemoimmunotherapy]
According to PharmaCloud, this patient has no records of visiting other healthcare facilities in the past three months. The repeat prescriptions for Baraclude (entecavir) and Harnalidge (tamsulosin), issued on 2023-08-10 by our hospital OPD, are currently on the active medication list and no reconciliation issues have been identified.
[bedside visit]
[exam findings]
[MedRec]
[consultation]
2023/06/16 AST 237 ALT 441 ALP 430 GGT 1489 TBI 2.97 DBI 1.74; WBC 9.65 Seg 94.8% CRP 1.2 PCT 0.36
2023/06/23 AST 68 ALT 127 ALP 239 GGT 993 TBI 5.64 DBI 3.43 PT 11.5 NH3 51
2023/06/17 HBsAg-/AntiHBs+/AntiHCV-
2023/06/23 TSH 0.053 (low), T3 0.67 (low) FT4 1.27; cortisol 17.74
[treatment]
2023-07-07 ~ undergoing - Xtandi (enzalutamide 40mg) 4# QDAC
2023-07-10 - Zoladex Depot (goserelin 3.6mg) SC ST
2023-05-09 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital
2023-04-11 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital
2023-05-09 - Xgeva (denosumab)
2023-04-11 - Xgeva (denosumab)
[hyperbilirubinemia]
This patient’s blood bilirubin level has increased significantly since late August.
2023-09-04 Bilirubin total 25.09 mg/dL 2023-08-31 Bilirubin total 19.49 mg/dL 2023-08-29 Bilirubin total 19.02 mg/dL 2023-08-29 Bilirubin total 19.02 mg/dL 2023-08-28 Bilirubin total 18.30 mg/dL 2023-08-24 Bilirubin total 13.31 mg/dL 2023-08-21 Bilirubin total 10.81 mg/dL 2023-08-17 Bilirubin total 6.25 mg/dL 2023-08-14 Bilirubin total 3.61 mg/dL 2023-08-10 Bilirubin total 1.49 mg/dL 2023-08-08 Bilirubin total 1.03 mg/dL 2023-08-07 Bilirubin total 1.19 mg/dL
2023-09-04 Bilirubin direct 14.35 mg/dL 2023-08-31 Bilirubin direct 12.67 mg/dL 2023-08-29 Bilirubin direct 12.16 mg/dL 2023-08-29 Bilirubin direct 12.16 mg/dL 2023-08-28 Bilirubin direct 9.94 mg/dL 2023-08-24 Bilirubin direct 7.89 mg/dL 2023-08-21 Bilirubin direct 6.44 mg/dL 2023-08-17 Bilirubin direct 3.58 mg/dL 2023-08-14 Bilirubin direct 2.11 mg/dL 2023-08-10 Bilirubin direct 0.74 mg/dL 2023-08-08 Bilirubin direct 0.37 mg/dL
Upon reviewing all drugs on the active medication list, 3 drugs are found to be associated with liver-related adverse reactions:
[Brosym 1000mg Q12H for patients with CrCl < 15mL/min]
Patient: Male, 70 years old, weighing 52kg, with a creatinine level of 3.58mg/dL, resulting in a creatinine clearance (CrCl) of 14mL/min.
According to the Sanford Guide, the recommended maximum dose of sulbactam for patients with a CrCl < 15mL/min is 500mg every 12 hours. Therefore, the appropriate dose for this patient would be Brosym 1000mg every 12 hours.
[to increase the dose of long-acting insulin]
Considering that fasting blood glucose levels from 2023-07-10 to 2023-07-12 are still on the high side, ranging around 200mg/dL to 300mg/dL, even with the current insulin regimen of Apidra (insulin glulisine) 3 units TIDAC and Tresiba (insulin degludec) 6 units HS for days, it is recommended to increase the dosage of Tresiba from 6 units to 7 units and continue monitoring blood glucose levels to determine if further adjustments are necessary.
[bilirubin level follow-up]
The patient’s bilirubin levels have remained stable over the past two weeks.
Upon reviewing the drugs in the patient’s active medication list, there is no clear evidence suggesting a need to adjust the dosages based on the current state of the patient’s liver function.
[bedside visit]
I visited the patient around 09:15 on 2023-07-10. He was lying in bed with his eyes closed, and his wife and a caregiver were present in the room. The patient didn’t respond when I conversed with his wife and the caregiver.
The patient’s caregiver mentioned that the patient’s feet were cold, so she placed a warm water bag near his feet to try to provide warmth. The patient’s wife reported that the patient had begun to sweat profusely on his head the previous night (without night sweats from the body), had not slept all night, and had a poor appetite, eating only a small amount.
Upon asking about the patient’s pain, bowel movements, and breathing, the caregiver indicated that the patient’s stools were regular, but his urine output was reduced due to concerns about pulmonary edema and fluid retention leading to reduced fluid intake. The patient continues to experience occasional shortness of breath and expresses discomfort, but there has been no significant increase in the intensity or duration of pain.
[Zoladex (goserelin)]
There is no dosage adjustment necessary for Zoladex (goserelin) in kidney impairement and/or hepatic impairment patients.
NHI provides coverage for the use of Gn-RH analogs, such as goserelin, exclusively for conditions like prostate cancer, central precocious puberty, endometriosis, and breast cancer in pre-menopausal (or peri-menopausal) cases. This patient should meet the criteria for coverage.
[bedside visit: breathing smoother]
I visited the patient on 2023-07-06 at approximately 10:30. The patient was in bed, using an oxygen mask with his eyes closed, and his wife and daughter were in the room with him. I noticed that the patient’s breathing did not seem rapid. I asked his wife and daughter about the patient’s condition, and his daughter replied that the patient’s breathing seemed smoother than it had been in the past few days and that there were no specific problems at the moment. When I asked if they had any questions about the medication or wanted to understand more, they indicated that they did not have any at this time.
[patient education: enzalutamide]
The patient agreed to use Xtandi (enzalutamide). I prepared an information sheet about enzalutamide, highlighting points the patient should be aware of, as well as potential side effects of the medication. At approximately 14:10 on 2023-07-06, I visited the patient, who was resting in the room with his daughter and caregiver. I gently woke the patient’s daughter and gave her the highlighted sheet. I also gave her the contact information for the pharmacy window and encouraged her to call if she had any questions about the medication.
[Minutes of the Multidisciplinary Team Meeting and Patient Family Meeting]
Today, on 2023-06-30 at around 11:45, Dr. Hsia gathered the patient’s daughter and the patient’s wife’s brother, and explained the current status of the patient’s condition using medical images. Then, from 12:15 to 13:15, a multidisciplinary team meeting and family meeting was held in the ward conference room. The meeting was chaired by Dr. Hsia and included members such as the nurse practitioner, the head nurse of the ward, the charge nurse, the social worker, and myself as the pharmacist. The the patient’s family representatives included the patient’s daughter and the patient’s wife’s brother. Dr. Hsia first clarified several key observations and considerations about the patient’s current condition. I presented the rationale behind the selection of anti-androgen agents, taking into account the expected changes in liver function. In addition, each of the nursing professionals also expressed their own perspectives.
Going forward, the pharmacy will continue to collaborate with the entire team in the management of this patient.
[bedside visit]
I visited the patient around 13:15 on 2023-06-30. The patient was using an oxygen mask, and his wife was standing by his bed. I asked about the patient’s current condition, and his wife indicated that he still had difficulty breathing, but he no longer coughed up blood. Upon checking the patient’s feet, I did not find any signs of lower limb edema.
[Rationale for the Selection of Anti-Androgen Agents in Patients with Potential Hepatic Impairment]
We currently have three anti-androgen medications in stock: Casodex (bicalutamide 50mg), Xtandi (enzalutamide 40mg), and Nubeqa (darolutamide 300mg), with the last one is a temporary purchase item and thus limited its use for certain patients.
Considering the patient’s normal AST and ALT levels along with elevated bilirubin (direct 0.78mg/dL, total 1.71mg/dL) as of 2023-05-29, the patient’s liver function should be taken into account when prescribing these drugs.
In conclusion, enzalutamide appears to be least affected by liver function and could be a reasonable choice if the patient’s liver function is not expected to recover in the short term.
The PharmaCloud database does not disclose any data for this patient, which could be due to the patient not having granting access.
In the past 3 years, there have been no records of outpatient or inpatient services for this patient at our hospital prior to this hospitalization. Consequently, no medication reconciliation issues have been detected.
Since the patient’s admission, fasting blood glucose levels have consistently ranged between 200 and 300 mg/dL, even with the administration of regular insulin 2 units PRNQ6H. To better manage these elevated blood sugar levels, it is advisable to increase the insulin dose to 3 units just before each meal. This approach trys to prevent blood glucose levels from exceeding 200 mg/dL. Continue to monitor blood glucose readings to assess the effectiveness of this adjustment and determine if further changes are needed.
The fasting serum glucose levels since this hospitalization were between 200 and 300 mg/dL even under regular insulin 2 units PRNQ6H. It is recommended to increase the dose to 3 unit right before each prandial to keep the blood sugar level at least not exceed 200mg/dL and keep monitoring the readings to decide if furthur adjustment necessary.
[exam findings]
[MedRec]
[radiotherapy]
[chemotherapy]
After reviewing the PharmaCloud and HIS5 records, no issues with medication reconciliation were identified. However, a blood glucose level of 263mg/dL recorded at 06:21 on 2023-09-05 suggests that glucose control may be suboptimal despite the use of multiple antidiabetic medications. Continuous monitoring of blood sugar levels is recommended to identify any developing trends.
[hypertriglyceridemia > 1000mg/dL]
During the months of June and July, there was a significant increase in triglyceride levels, leading to severe hypertriglyceridemia (exceeding 1000 mg/dL). Elevated triglycerides could interfere with an initial stage of the insulin signaling pathway, or conversely, insulin resistance might be contributing to the hypertriglyceridemia.
2023-08-26 Triglyceride (TG) 2209 mg/dL
2023-08-19 Triglyceride (TG) 1581 mg/dL
2023-08-05 Triglyceride (TG) 1183 mg/dL
2023-07-29 Triglyceride (TG) 2254 mg/dL
2023-07-22 Triglyceride (TG) 1814 mg/dL
2023-07-13 Triglyceride (TG) 2383 mg/dL
2023-07-08 Triglyceride (TG) 1802 mg/dL
2023-06-03 Triglyceride (TG) 597 mg/dL
2023-05-06 Triglyceride (TG) 491 mg/dL
2023-04-08 Triglyceride (TG) 495 mg/dL
2023-03-11 Triglyceride (TG) 409 mg/dL
2023-02-11 Triglyceride (TG) 318 mg/dL
2023-01-14 Triglyceride (TG) 309 mg/dL
Hypothyroidism is most often associated with hypercholesterolemia (2023-07-08 cholestrol total 355 mg/dL), but association with hypertriglyceridemia has also been described. Ref: Thyroid function and prevalent and incident metabolic syndrome in older adults: the Health, Ageing and Body Composition Study. Clin Endocrinol (Oxf). 2012;76(6):911-918. doi:10.1111/j.1365-2265.2011.04328.x
When the TG level is >1000 mg/dL, drugs used to lower TG have limited effectiveness. These agents work primarily by reducing hepatic TG synthesis and secretion as VLDL-TG and thus are relatively ineffective when TG level is severely elevated.
[patient education]
At around 15:15 on 2023-06-20, I visited the patient, who was resting with her eyes closed. Her sister, who was sitting in a chair next to the bed, woke her up. I brought the patient information leaflets for paclitaxel and carboplatin, explaining the potential side effects of each drug one by one. I asked her to inform the medical team as soon as possible if any suspicious symptoms occur. The patient reported that she had previously told Dr. Wan about numbness in her fingertips after chemotherapy, and stated that this condition still persists at the time of this visit.
Although carboplatin has been linked to peripheral neuropathy in 4% to 6% of cases, the association is even stronger with paclitaxel, which is linked to peripheral neuropathy in 42% to 70% of cases (grades 3/4 <= 7%). Therefore, it’s more probable that the numbness in the patient’s fingertips is primarily due to paclitaxel.
The 2020 ASCO guidelines suggest that clinicians may consider offering duloxetine to patients with chemotherapy-induced peripheral neuropathy. Additionally, the 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for the treatment of neuropathic pain in this context. Reference: “Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325”.
We currently have Cymbalta (duloxetine 30mg/cap) in stock. For chemotherapy-induced peripheral neuropathy, the oral initial dose is 30 mg once daily for 1 week, then increased to 60 mg once daily. (ref: UpToDate)
[exam findings]
[consultation]
The patient monthly refills for his repeat prescription medications, which include famotidine, silymarin, vitamin B complex, and propranolol, with the last refill occurring on 2023-08-06. Please confirm whether these medications are no longer required for the patient’s current medical status.
[MedRec]
On 2023-08-05, the patient received a 30-day prescription for pioglitazone, linagliptin, pentoxifylline, amlodipine, irbesartan, and atorvastatin. Not all of these medications are currently on the list of active medications. Please check to see if any of these medications are no longer needed.
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
[vancomycin dosing for adults with normal kidney function]
Loading dose (for patients with known or suspected severe Staphylococcus aureus infection) 20 to 35 mg/kg (based on actual body weight, rounded to the nearest 250 mg increment; not to exceed 3000 mg). Within this range, we use a higher dose for critically ill patients; we use a lower dose for patients who are obese and/or are receiving vancomycin via continuous infusion. The patient’s weight is approximately 50 kg, which suggests a loading dose range of 1000mg to 1750mg. The administered dose of 1000mg on 2023-08-28 at 10:49 falls on the lower end of this range.
Initial maintenance dose and interval typically 15 to 20 mg/kg every 8 to 12 hours for most patients (based on actual body weight, rounded to the nearest 250 mg increment). The dosage of 20mg/kg every 12 hours is then being administered to this date currently.
Given the lower initial loading dose and the recently observed elevated trough level of 16.5 mg/L (2023-08-31 morning), a 20% reduction in the current dosage is recommended, which equates to administering 800mg Q12H.
[lab data]
2023-07-27 LDH 150 U/L
2023-07-20 B2-Microglobulin 2197 ng/mL
2023-07-18 BM chromosome analysis - cytogenetics laboratory report
2023-07-13 B2-Microglobulin 2254 ng/mL
2023-07-12 LDH 142 U/L
2023-06-21 Anti-HBc Reactive
2023-06-21 Anti-HBc-Value 4.63 S/CO
2023-06-21 Anti-HBs 297.01 mIU/mL
2023-06-21 HBsAg Nonreactive
2023-06-21 HBsAg (Value) 0.35 S/CO
[exam findings]
[MedRec]
[immunochemotherapy]
[Dipeptiven dosage and administration]
(Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf)
Solution for infusion after mixture with a compatible infusion solution. Solutions of mixtures with an osmolarity above 800 mosmol/L should be infused by the central venous route.
Dipeptiven is administered parallel with parenteral nutrition or enteral nutrition or a combination of both. Dosage depends on the severity of the catabolic state and on amino acids/protein requirement.
A maximum daily dosage of 2 g amino acids/or protein per kg bodyweight should not be exceeded in parenteral/enteral nutrition. The supply of alanine and glutamine via Dipeptiven should be taken into consideration in the calculation. The proportion of the amino acids supplied through Dipeptiven should not exceed approx. 30% of the total amino acids/protein supply.
[Selection of antiviral drugs for Hepatitis B]
This patient is undergoing dialysis, and the current administration methods for Hepatitis B medication available in our hospital for dialysis patients are:
Considering the patient’s bilirubin levels on 2023-08-30, with total bilirubin at 2.32mg/dL and direct bilirubin at 1.78mg/dL, the use of Baraclude 0.5mg QWAC may be an option.
The patient renewed his prescription on 2023-08-03 for metformin, aspirin, bisoprolol, amlodipine, and atorvastatin. Comparing with the active medication list, statins are not listed. Lab results from 2023-08-04 indicated no hyperlipidemia. Thus, there are no identified issues with medication reconciliation.
2023-08-04 Cholesterol total 148 mg/dL
2023-08-04 Triglyceride (TG) 95 mg/dL
2023-08-04 LDL-C 95 mg/dL
2023-08-04 HDL-C 43 mg/dL
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
Based on PharmaCloud records, this patient has only received medical care at our hospital in the last three months, with no medication reconciliation issues identified.
從 PharmaCloud 紀錄來看，該名患者最近三個月只在本院就診，沒有發現 medication reconciliation issue.
[lab data]
2023-08-14 CMV viral load assay Target not detecetedIU/mL
2023-08-09 CD45+Total leukocyte 329085 /uL
2023-08-09 %CD34+ 0.41 %
2023-08-09 CD34+ Count 1350 /uL
2023-08-09 CD45+Total leukocyte 25806 /uL
2023-08-09 %CD34+ 0.10 %
2023-08-09 CD34+ Count 26 /uL
2023-08-09 HPC Ratio 0.41 %
2023-08-09 HPC# 0.1050 10^3/ul
2023-08-08 CD45+Total leukocyte 367310 /uL
2023-08-08 %CD34+ 0.31 %
2023-08-08 CD34+ Count 1140.0 /uL
2023-08-08 RPR/VDRL Nonreactive
2023-08-08 HIV Ab-EIA Nonreactive
2023-08-08 Anti-HIV Value 0.07 S/CO
2023-08-08 Anti-HCV Nonreactive
2023-08-08 Anti-HCV Value 0.09 S/CO
2023-08-08 HBsAg Nonreactive
2023-08-08 HBsAg (Value) 0.27 S/CO
2023-08-08 CD45+Total leukocyte 22719 /uL
2023-08-08 %CD34+ 0.10 %
2023-08-08 CD34+ Count 24.0 /uL
2023-08-08 HPC Ratio 0.34 %
2023-08-08 HPC# 0.0820 10^3/ul
2023-07-18 IgG (blood) 732 mg/dL
2023-06-06 Free Light Chain κ/λ, (blood) ratio
2023-06-06 FKLC 9.6 mg/L
2023-06-06 FLLC 86.8 mg/L
2023-06-06 FK/FL ratio 0.11 ratio
2023-06-01 B2-Microglobulin 1862 ng/mL
2023-05-31 IgG (blood) 867 mg/dL
2023-05-23 CD45+Total leukocyte 216525 /uL
2023-05-23 %CD34+ 0.13 %
2023-05-23 CD34+ Count 285 /uL
2023-05-23 CD45+Total leukocyte 36136 /uL
2023-05-23 %CD34+ 0.02 %
2023-05-23 CD34+ Count 6 /uL
2023-05-23 HPC Ratio 0.04 %
2023-05-23 HPC# 0.018 10^3/ul
2023-05-22 CD45+Total leukocyte 243730 /uL
2023-05-22 %CD34+ 0.31 %
2023-05-22 CD34+ Count 760 /uL
2023-05-22 HPC Ratio 0.18 %
2023-05-22 HPC# 0.094 10^3/ul
2023-05-03 Free Light Chain κ/λ; (blood) ratio
2023-05-03 FKLC 11.2 mg/L
2023-05-03 FLLC 53.5 mg/L
2023-05-03 FK/FL ratio 0.21 ratio
2023-04-27 B2-Microglobulin 1275 ng/mL
2023-04-26 IgG (blood) 782 mg/dL
2023-04-11 CD45+Total leukocyte 246285 /uL
2023-04-11 %CD34+ 0.08 %
2023-04-11 CD34+ Count 200 /uL
2023-04-11 CD45+Total leukocyte 24252 /uL
2023-04-11 %CD34+ 0.01 %
2023-04-11 CD34+ Count 2 /uL
2023-04-11 HPC Ratio 0.15 %
2023-04-11 HPC# 0.036 10^3/ul
2023-04-10 CD45+Total leukocyte 191835 /uL
2023-04-10 %CD34+ 0.11 %
2023-04-10 CD34+ Count 205 /uL
2023-04-10 CD45+Total leukocyte 30658 /uL
2023-04-10 %CD34+ 0.02 %
2023-04-10 CD34+ Count 6 /uL
2023-04-10 HPC Ratio 0.21 %
2023-04-10 HPC# 0.062 10^3/ul
2023-03-31 Free Light Chain κ/λ; (blood) ratio
2023-03-31 FKLC 9.4 mg/L
2023-03-31 FLLC 55.1 mg/L
2023-03-31 FK/FL ratio 0.17 ratio
2023-03-25 B2-Microglobulin 1833 ng/mL
2023-03-24 IgG (blood) 621 mg/dL
2023-03-13 Free Light Chain κ/λ; (blood) ratio
2023-03-13 FKLC 9.6 mg/L
2023-03-13 FLLC 87.3 mg/L
2023-03-13 FK/FL ratio 0.11 ratio
2023-03-04 B2-Microglobulin 1701 ng/mL
2023-03-03 IgG (blood) 880 mg/dL
2023-02-23 Influenza A Ag Negative
2023-02-23 Influenza B Ag Negative
2023-02-08 Free Light Chain κ/λ; (blood) ratio
2023-02-08 FKLC 15.1 mg/L
2023-02-08 FLLC 231.25 mg/L
2023-02-08 FK/FL ratio 0.07 ratio
2023-02-04 B2-Microglobulin 2002 ng/mL
2023-02-03 IgG (blood) 757 mg/dL
2022-12-22 Free Light Chain κ/λ; (blood) ratio
2022-12-22 FKLC 13.4 mg/L
2022-12-22 FLLC 287.5 mg/L
2022-12-22 FK/FL ratio 0.05 ratio
2022-12-17 B2-Microglobulin 2642 ng/mL
2022-12-16 IgG (blood) 1463 mg/dL
2022-11-29 HBsAg Nonreactive
2022-11-29 HBsAg (Value) 0.41 S/CO
2022-11-29 Anti-HCV Nonreactive
2022-11-29 Anti-HCV Value 0.24 S/CO
2022-11-29 Anti-HBc Reactive
2022-11-29 Anti-HBc-Value 6.61 S/CO
2022-11-29 Anti-HBc IgM Nonreactive
2022-11-29 Anti-HBc IgM Value 0.09 S/CO
2022-11-29 Anti-HBs 9.54 mIU/mL
2022-11-24 CD2 NA
2022-11-24 CD3 61.7
2022-11-24 CD4 19.9
2022-11-24 CD5 75.6
2022-11-24 CD7 82.3
2022-11-24 CD8 52.2
2022-11-24 CD10 12.5
2022-11-24 CD11b NA
2022-11-24 CD13 NA
2022-11-24 CD14 3.9
2022-11-24 CD15 NA
2022-11-24 CD16 NA
2022-11-24 CD19 19.5
2022-11-24 CD19/kappa 7.27
2022-11-24 CD19/Lambda 9.4
2022-11-24 CD20 25.7
2022-11-24 CD23 18.9
2022-11-24 CD25 16.5
2022-11-24 CD33 NA
2022-11-24 CD34 6.9
2022-11-24 CD38 85.2
2022-11-24 CD56 29.1
2022-11-24 CD103 NA
2022-11-24 CD117 NA
2022-11-24 CD138 16.2
2022-11-24 FMC7 19.3
2022-11-24 HLA-DR NA
2022-11-24 MPO NA
2022-11-24 TdT NA
2022-11-23 BM chromosome analyz see attachment
2022-11-10 Free Light Chain κ/λ; (urine)
2022-11-10 Total Volume(24hr) 4500 mL
2022-11-10 FKLC 28.8 mg/L
2022-11-10 FLLC 6875 mg/L
2022-11-10 FK/FL ratio 0.004189
2022-11-08 IgD; <46.7 U/mL
2022-11-08 Free Light Chain κ/λ; (blood) ratio
2022-11-08 FKLC 14.0 mg/L
2022-11-08 FLLC 2725 mg/L
2022-11-08 FK/FL ratio 0.01 ratio
2022-11-07 Protein EP; (urine)
2022-11-07 Protein (Urine) 334 mg/dL
2022-11-07 Albumin(Urine) 4.8 %
2022-11-07 Alpha-1 0.9 %
2022-11-07 Alpha-2 1.1 %
2022-11-07 Beta 2.8 %
2022-11-07 Gamma 90.4 %
2022-11-07 A/G Ratio (Urine) 0.1
2022-11-05 Protein EP;
2022-11-05 Protein, total 8.8 g/dL
2022-11-05 Albumin 35.0 %
2022-11-05 Alpha-1 1.8 %
2022-11-05 Alpha-2 9.7 %
2022-11-05 Beta 8.6 %
2022-11-05 Gamma 44.9 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50
2022-11-05 Protein, total 9.0 g/dL
2022-11-05 Albumin 35.3 %
2022-11-05 Alpha-1 2.4 %
2022-11-05 Alpha-2 9.5 %
2022-11-05 Beta 8.5 %
2022-11-05 Gamma 44.3 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50
2022-11-05 IgG/A/M Kappa/Lambda IgG + Lambda chain
2022-11-05 IgE 13.4 IU/mL
2022-11-04 B2-Microglobulin 2800 ng/mL
2022-11-03 IgG (blood) 4374 mg/dL
2022-11-03 IgA 95 mg/dL
2022-11-03 IgM 34.0 mg/dL
2022-11-03 Total protein 9.4 g/dL
[MedRec]
[family meeting minutes prior to ASCT]
On 2023-08-30 at 10:15 in the ward conference room, Dr. Gao chaired a family meeting with the patient and his relatives. Attendees included the patient himself, his wife, and his daughter, while his son joined via phone. Dr. Gao explained the treatment plan, the importance and potential risks of autologous stem cell transplantation as a treatment method, and allowed family members to ask questions freely during the meeting.
Overall, the family seemed supportive, and the patient indicated that he would be willing to use a nasogastric tube if necessary during the transplantation treatment. His daughter asked if mouthwash could alleviate symptoms of oral mucositis, to which Dr. Gao responded that mouthwash could help maintain oral cleanliness but couldn’t completely prevent or mitigate the condition, which is mainly caused by conditioning agents.
After the meeting, some casual conversation with the family revealed that the patient was a chef and had run his own business in the past. After retiring, he assisted with religious services in several temples. He is also a vegetarian and has no objections to the hospital’s food offerings.
[Evomela (melphalan) as conditioning regimen prior to HSCT for multiple myeloma]
The recommended dosing schedule is IV 100 mg/m2 daily for 2 days on day -3 and day -2 prior to autologous stem cell transplantation on day 0. Ref: Hari P, Aljitawi OS, Arce-Lara C, et al. A Phase IIb, Multicenter, Open-Label, Safety, and Efficacy Study of High-Dose, Propylene Glycol-Free Melphalan Hydrochloride for Injection (EVOMELA) for Myeloablative Conditioning in Multiple Myeloma Patients Undergoing Autologous Transplantation. Biol Blood Marrow Transplant. 2015;21(12):2100-2105. doi:10.1016/j.bbmt.2015.08.026
[MedRec]
[chemotherapy]
In the last three months, all medical records on PharmaCloud are from this hospital. Currently, no medication reconciliation issues have been identified.
(not completed)
[MedRec]
[immunochemotherapy]
On 2023-07-09, the patient refilled her repeat prescription for atenolol and valsartan to manage her primary hypertension. This prescription was originally issued by JingMei Hospital on 2023-06-15. Both medications have been added to the active medication list, and there are no reconciliation issues detected.
[MedRec]
[surgical operation]
[chemotherapy]
[immunochemotherapy]
2023-08-07 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)
2023-07-19 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)
2023-07-05 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)
2023-06-28 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)
2023-06-21 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)
2023-06-14 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)
2023-06-07 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)
2023-06-07 - trastuzumab 6mg/kg 350mg NS 250mL 90min (Chang YaoRen)
2023-02-10 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)
2023-01-27 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)
2023-01-12 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)
2022-12-29 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)
2022-12-07 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-11-16 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-10-26 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-10-05 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-09-14 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-08-24 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-08-03 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-07-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-06-22 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-05-25 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-05-04 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2023-04-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2023-03-23 - trastuzumab 6mg/kg 375mg NS 250mL 90min
2022-03-02 - trastuzumab 6mg/kg 360mg NS 250mL 90min
2022-02-09 - trastuzumab 6mg/kg 360mg NS 250mL 90min
2022-01-19 - trastuzumab 6mg/kg 360mg NS 250mL 90min
2021-12-29
2021-12-08
2021-11-17
2021-10-27
2021-10-06
2021-09-15
2021-08-25
2021-08-04
2021-07-14
2021-06-23
2021-06-02
2021-05-05
2021-04-14
2021-03-24
2021-03-03 - trastuzumab emtansine 230mg NS 250mL 1.5hr
2021-02-10 - trastuzumab emtansine 230mg NS 250mL 1.5hr
2021-01-11
2020-12-21
2020-11-30
2020-11-09
2020-10-19
2020-09-28
2020-09-07
2020-08-17
2020-07-27
2020-07-06
2020-06-22
2020-06-15
2020-06-03
2020-05-27
2020-05-13
2020-05-06
2020-04-22
2020-04-15
2020-04-01 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min
2020-03-25 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min
2020-03-11 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min
2020-03-04 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min
2020-02-10 - trastuzumab 600mg SC 5min
2020-01-20 - trastuzumab 600mg SC 5min
[cachexia]
The patient has lost 10 kg in three months, from 63.2 kg on 2023-05-25 to 52.5 kg on 2023-08-11. To combat this significant weight loss, it’s important to improve the patient’s nutritional intake. In the absence of dysphagia, megestrol can be introduced as an appetite stimulant at a suggested dosage of 200 to 600 mg/day to counteract anorexia.
[oral mucotitis]
For oral mucotitis, the introduction of Nincort Oral Gel (triamcinolone) is recommended to relieve discomfort.
[MedRec]
The patient renewed a repeat prescription for insulin degludec, linagliptin, clopidogrel, doxazosin, bisoprolol, pitavastatin, levothyroxine, and ginkgo biloba extract on 2023-08-04. Some of these medications are not listed in the active medication list. Please verify if the unlisted medications are no longer required.
[exam findings]
[MedRec]
There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.
[exam findings]
[consultation]
[surgical operation]
[immunochemotherapy]
No medication reconciliation issues were identified after reviewing PharmaCloud and HIS5 records.
The repeat prescription issued by NTUH was refilled on 2023-08-01 and includes Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), and Xanax (alprazolam). These medications are currently being used with no reconciliation issues identified.
This patient visited NTUH on 2023-06-15 and was prescribed Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), Xanax (alprazolam) which were refilled at a local pharmacy on 2023-07-03. These drugs are now in the active medication list, no reconciliation issues found.
Upon examining the PharmaCloud database, it appears that access to this patient’s information is currently unavailable, potentially due to lack of authorization. However, a review of the HIS5 medication records indicates that all valid prescriptions were provided by the Hemato-Oncology department. Hence, no medication reconciliation issues have been found.
[exam findings]
[MedRec]
This patient received a repeat prescription on 2023-06-28 at NTUH HsinChu Branch and refilled it on 2023-07-20 at a local pharmacy for a 28-day supply of Sennapur (sennoside), Betmiga (mirabegron), Xanax (alprazolam), and Eurodin (estazolam). There is no mirabegron included in the active medication list, please confirm if the drug is no longer needed.
[MedRec]
[MedRec]
[MedRec]
[radiotherapy]
[chemotherapy]
[lab data]
2023-05-19 Anti-HBs 1.62 mIU/mL
2023-05-19 Anti-HCV Nonreactive
2023-05-19 Anti-HCV Value 0.12 S/CO
2023-05-19 HBsAg Reactive
2023-05-19 HBsAg (Value) 3220.93 S/CO
2023-05-19 Anti-HBc Reactive
2023-05-19 Anti-HBc-Value 8.80 S/CO
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
No reconciliation issues found after reviewing PharmaCloud and HIS5 records.
As of 2023-05-19, the patient has tested reactive for Anti-HBc. Baraclude (entecavir 0.5mg) 1# QDAC has been appropriately prescribed. The patient’s vital signs are currently stable and there are no issues with the active prescription.
[exam findings]
[consultation]
[radiotherapy]
[chemotherapy]
After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.
[diagnosis] - 2023-03-22 discharge note
[past history] - 2023-04-05 admission note
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
2023-08-11 Radiation Oncology
2023-08-11 Family Medicine
2023-08-11 Ear Nose Throat
2023-04-07 Infectious Disease
2023-04-07 Chest Medicine
2023-04-07 Cardiology
2023-02-22 Vascular Surgery
[chemotherapy]
[tube feeding: Detrusitol SR (tolterodine), Valcyte F.C (valganciclovir)]
Based on the information for Valcyte F.C (valganciclovir), the drug should not be crushed for tube feeding because animal data suggests that valganciclovir has the potential to be carcinogenic in humans. As this hospital does not have access to foscarnet or cidofovir, and ganciclovir shares a similar potential carcinogenic risk, it seems that continuing with Valcyte for tube feeding is the only option at this stage.
Detrusitol SR (tolterodine) is an extended-release capsule, and crushing it for tube feeding could compromise its prolonged-release properties. This could result in a more pronounced fluctuation in its concentration in the bloodstream, potentially affecting its therapeutic efficacy. All other in-hospital available drugs within the same class as tolterodine, such as Urotrol F.C (propiverine 15mg), Oxbu ER (oxybutynin 5mg), Vesicare F.C (solifenacin 5mg), and Betmiga (mirabegron 50mg), are designed as film-coated or extended-release. It might be beneficial to divide the dosage of Detrusitol into two administrations per day to stabilize the concentration in the bloodstream for tube feeding.
Patients undergoing treatment with immunosuppressive drugs are at an increased risk of developing Pneumocystis pneumonia (PCP). This risk is particularly heightened in patients who are receiving glucocorticoids in combination with cytotoxic agents such as cyclophosphamide, and in those receiving multiple chemotherapeutic agents, especially during periods of leukopenia. As a measure against PCP, the patient has been prescribed Morcasin (containing trimethoprim 80mg and sulfamethoxazole 400mg, also known as TMP-SMX). Given that the patient doesn’t show signs of renal insufficiency (based on 2023-05-15 lab data), there is no need for a dose adjustment.
Lab data reveals that the patient’s CMV viral load, which had peaked at 803 IU/mL on 2023-05-02, has now decreased to less than 35 IU/mL as of today, 2023-05-15. Valganciclovir, the active ingredient in Valcyte, is an oral prodrug that is rapidly converted into ganciclovir, a substance instrumental in the treatment and prevention of CMV infections in immunocompromised hosts. The marked decrease in CMV viral load suggests that the prescribed Valcyte is effectively managing the CMV infection.
As per the PharmaCloud records, all of the patient’s recent medications have been prescribed by our hospital, and no issues related to medication reconciliation have been identified.
2023-04-05 lab data showed elevated CRP, NT-proBNP, hs-Troponin I, D-dimer, as well as hyponatremia, leukopenia and anemia. Liver and kidney functions were normal. Cardiologist has been consulted.
Pneumonia with exaggerated dyspnea and hypoxemia was observed on admission; planned chemotherapy is withheld until respiratory symptoms resolve. Brosym (cefoperazone + sulbactam) has been prescribed since the day the patient was admitted.
Rivaroxaban and amlodipine have been prescribed properly as self-carried items with no medication reconciliation issues.
[exam findings]
[consultation]
[chemoimmunotherapy]
[exam findings]
[MedRec]
2023-08-10 SOAP Radiation Oncology
2023-08-02 SOAP Hemato-Oncology Xia HeXiong
2023-07-27 SOAP Hemato-Oncology Gao WeiYao
2023-07-27 SOAP Radiation Oncology
2023-07-19 ~ 2023-07-20 POMR Gastroenterology
2023-07-04 SOAP Hemato-Oncology Gao WeiYao
2023-07-04 SOAP Radiation Oncology
2023-06-21 SOAP Cardiology
2023-06-20 SOAP Metabolism and Endocrinology
[consultation]
[radiotherapy]
[chemotherapy]
[reconciliation]
A repeat prescription was issued by our cardiologist on 2023-06-21 and was refilled on 2023-08-06 for Algitab (alginic acid, MgCO3, Al(OH)3), Eurodin (estazolam), Concor (bisoprolol), and Sevikar (amlodipine 5mg, olmesartan 20mg). All of these refilled drugs, except for Algitab, have been included in the formulary. Please confirm whether Algitab is still necessary for the patient.
[FDG-PET/CT in detecting cancers with unknown primary site depends on histological subtype]
On 2023-07-20, the pathologic analysis results of the liver biopsy needle/wedge did not reveal any evidence of hepatocytic or cholangiocytic differentiation based on ICH staining. Therefore, the primary origin of the condition remains unidentified. An article titled “The usefulness of FDG-PET/CT in detecting and managing cancers with unknown primary site depends on histological subtype. Sci Rep. 2021;11(1):17732. Published 2021 Sep 6” highlighted the following key points:
In light of this, the use of PET could be an optional tool to help identify the origin of the biopsy liver lesion.
[diagnosis] - 2023-05-02 admission note
[past history]
Medical history: - Hypertension under Losa & hydro control for more than ten years - Type 2 diabetes mellitus under Dibose and Trajenta contro for two months - Hypothyrodism without medical control for over three years. - Hyperlipidemia with Zulitor F.C 4mg 0.5# po QD - Cerebral atherosclerosis with Plavix F.C 75mg 1# po QD
Surgical history: - Left knee osteoarthritis status post left total knee replacement on 2016. - Gastric perforation status post Billroth II for many years.
[allergy]
[family history]
[exam findings]
[consultation]
[MedRec]
[chemoimmunotherapy]
Revised Edition of Hematologic Oncology Chemotherapy Drug Prescription (in hospital regimen collection, version 2022-07-04)
Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-06-06 https://www.uptodate.com/contents/image?imageKey=ONC%2F63586&topicKey=HEME%2F4729
Cycle length: 21 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
Older patients with DLBCL generally have a worse prognosis compared to younger patients due, in part, to more comorbid conditions and lower treatment tolerance. 2023-06-06 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma
Our endocrinologist wrote a repeat prescription for Zulitor (pitavastatin), Trajenta (linagliptin 5mg) and Dibose (acarbose 100mg) on 2023-08-02 and the drugs are included in the formulary with no reconciliation issue identified.
On 2023-06-08, our neurologist issued a refillable prescription for Plavix (clopidogrel) and diphenidol, and on 2023-06-23, our otolaryngologist prescribed Strocain (oxethazaine polymigel), Acetal (acetaminophen), and cephalexin. Apart from diphenidol, which is no longer necessary due to the resolution of vertigo, all other validly prescribed drugs mentioned have been incorporated into the active medication list without any reconciliation issues.
This patient visited local medical doctor on 2023-05-26, 2023-05-28, 2023-05-29, 2023-05-30, 2023-06-01, 2023-06-04 for her myositis, functional dyspepsia, acute upper respiratory infection, and prescribed acetaminophen, diazepam, loratadine and opium derivatives. for each a short 3-day valid prescription. These symptoms are generally covered in current medical problem list and managed with corresponding same or similar therapeutic class medications. No medication reconciliation issues identified.
Given that this patient has been diagnosed with myositis and dyspepsia that have persisted for months according to the PharmaCloud database, it’s plausible that these could be indicative of statin-induced muscle side effects. Clinical experience suggests that a change in dosing frequency, such as alternate day dosing, may improve statin tolerability in patients experiencing adverse effects such as myalgia. This strategy is particularly beneficial for patients who cannot tolerate daily statin therapy. In addition, alternate-day statin therapy is also considered a cost-effective method to improve drug utilization (Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017;31(4):419-431). Considering the information from these studies and the fact that the laboratory data indicate an improvement in the patient’s hyperlipidemia, it is recommended that the administration of Zulitor be changed from 0.5# QD to 0.5# QOD.
Due to the patient’s advanced age, R-miniCHOP (a dose-reduced version of R-CHOP with reduced amounts of cyclophosphamide and vincristine) was selected as treatment starting on 2023-03-31. One episode of leukopenia was observed (1.56K/uL on 2023-04-12) and was alleviated with two consecutive days of Granocyte (lenograstim) administration. Please monitor for recurrence of leukopenia after this 2nd dose of R-miniCHOP.
Beta-2 microglobulin (b2M) is a major histocompatibility complex (MHC) class I molecule found on the surface of nearly all nucleated cells in the body. Cells with a high turnover rate, such as immune cells and cancer cells, tend to produce and express higher levels of b2M on their surface. In non-Hodgkin’s lymphoma, cancer cells may also have elevated levels of b2M. The elevated levels of b2M observed around the trough of leukopenia may indicate the destruction of cancerous B cells.
Lab data showed that levels above the ULN are associated with type 2 diabetes and hyperlipidemia. Dibose (acarbose), Trajenta (linagliptin) and Zulitor (pitavastatin) are currently appropriately prescribed.
The patient’s cerebral atherosclerosis is treated with Plavix (clopidogrel) and her hepatitis B is treated with Baraclude (entecavir) without an issue.
Hypothyroidism is listed as a diagnosis for the patient, but there is no corresponding medication prescribed currently. The serum free T4 level on 2023-03-17 was 0.57 ng/dL, which is slightly below the normal range. It is recommended to reevaluate the patient’s condition and consider prescribing appropriate medication, such as levothyroxine, if necessary to manage her hypothyroidism.
[drug identification]
The three requested drugs have been identified as follows:
An in-hospital porter will be sent to deliver these medications to the patient’s ward.
[exam findings]
[MedRec]
2023-07-10 SOAP Colorectal Surgery
2020-06-16 SOAP Metabolism and Endocrinology
2018-12-04 SOAP Colorectal Surgery
2018-11-05 SOAP Colorectal Surgery
2017-03-06 SOAP Metabolism and Endocrinology
[chemotherapy]
On 2023-08-01, this patient obtained a 28-day supply of metformin, repaglinide, bisoprolol, olmesartan, and pitavastatin from Cheng Hsin General Hospital. It is noted that GLP-1 agonist (such as semaglutide) and HMG-CoA reductase inhibitor (like pitavastatin) are not currently listed in the active medication profile. It is advisable to closely observe the patient’s blood lipid and blood sugar levels to determine whether these medications or similar drugs within the same therapeutic class are necessary for his ongoing treatment.
[lab data]
2023-08-10 Anti-β2-glycoprotein-I Ab 0.6 U/mL
2023-08-10 Anti-cardiolopin IgG 0.7 GPL-U/mL
2023-08-10 Anti-cardiolipin IgM 1.3 MPL-U/mL
2023-08-08 CEA (NM) 89.031 ng/ml
2023-08-07 HBsAg Nonreactive
2023-08-07 HBsAg (Value) 0.36 S/CO
2023-08-07 Anti-HBc Reactive
2023-08-07 Anti-HBc-Value 6.47 S/CO
2023-08-07 Anti-HCV Nonreactive
2023-08-07 Anti-HCV Value 0.09 S/CO
2023-08-07 CEA 96.78 ng/mL
2023-08-07 CA199 29.24 U/mL
2023-08-07 D-dimer > 10000.00 ng/mL(FEU)
2023-08-07 PT 11.1 sec
2023-08-07 INR 1.08
2023-08-07 APTT 25.7 sec
2023-08-07 Fibrinogen(quantita) 364.4 mg/dL
2023-08-04 Alkaline phosphatase 931 U/L
[exam findings]
[MedRec]
[lab data]
2023-07-26 Anti-HBc Reactive
2023-07-26 Anti-HBc-Value 6.35 S/CO
2023-07-26 Anti-HBs 7.41 mIU/mL
2023-07-26 Anti-HCV Nonreactive
2023-07-26 Anti-HCV Value 0.23 S/CO
2023-07-26 HBsAg Nonreactive
2023-07-26 HBsAg (Value) 0.26 S/CO
[exam findings]
[MedRec]
[lab data]
2023-07-22 Anti-HBc Reactive
2023-07-22 Anti-HBc-Value 4.23 S/CO
2023-07-22 Anti-HCV Nonreactive
2023-07-22 Anti-HCV Value 0.13 S/CO
2023-07-22 Anti-HBs 5.84 mIU/mL
2023-07-22 HBsAg Nonreactive
2023-07-22 HBsAg (Value) 0.49 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[prophylactic antiviral therapy prior to immunosuppressive agent use]
The patient’s hepatitis B serology results indicate that he is immune due to natural infection, with negative HBsAg, positive anti-HBc, and positive anti-HBs. However, he remains vulnerable to reactivation if exposed to immunosuppressive agents.
Given this situation, if the treatment plan involves immunosuppressive agents, it is advisable to consider prophylactic antiviral therapy. Possible options include prescribing either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive approach can effectively lower the risk of potential HBV reactivation induced by the immunosuppressive effects of the treatment.
ref: Pharmacy FAQ - Hepatitis B reactivation and screening. http://www.bccancer.bc.ca/pharmacy-site/Documents/Pharmacy%20FAQs/Pharmacy-FAQ-Hepatitis-B.pdf
[MedRec]
Concor (bisoprolol) and Nexium (esomeprazole) should be prepared by the simple suspension method before tube feeding.
The simple suspension method refers to the process of placing tablets and capsules in warm water for a period of time and gently shaking them to promote disintegration and suspension of the medication, rather than grinding them into powder for tube feeding.
{rectal cancer with LNs, lung, sacrum, sacroiliac joints mets, stage IV}
[lab data]
2023-07-19 HBsAg (NM) Negative
2023-07-19 HBsAg Value (NM) 0.420
2023-07-19 Anti-HBs (NM) Negative
2023-07-19 Anti-HBs value (NM) <2.000 mIU/mL
2023-07-19 Anti-HBc (NM) Negative
2023-07-19 Anti-HBc Value (NM) 2.190
2021-06-02 KRAS 12/13 Sample No S2021-6919
2021-06-02 KRAS 12/13 mutation detected
2021-06-02 NRAS/KRAS Sample No S2021-6919
2021-06-02 NRAS/KRAS mutation Not detected
2021-05-14 HBsAg Nonreactive
2021-05-14 HBsAg (Value) 0.34 S/CO
2021-05-14 Anti-HBc Nonreactive
2021-05-14 Anti-HBc-Value 0.44 S/CO
2021-05-14 Anti-HCV Nonreactive
2021-05-14 Anti-HCV Value 0.06 S/CO
[exam finding]
[MedRec]
[chemoimmunotherapy]
2023-08-07 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-07-24 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-07-10 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-06-26 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-06-13 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-05-30 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-05-12 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-04-21 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)
2023-04-03 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)
2023-03-09 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)
2023-02-21 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)
2022-09-19 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-09-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-08-14 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-08-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-07-11 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-06-27 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 157mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-06-06 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 336mg 1.5hr + leucovorin 400mg/m2 748mg 2hr + fluorouracil 2800mg/m2 5235mg 46hr
2022-05-19 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr
2022-04-29 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr
2022-04-15 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5130mg 46hr
2022-03-23 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr
2022-03-09 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr
2022-02-22 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 348mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr
2022-02-08 - irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
2022-01-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
2022-01-04 - bevacizumab 5mg/kg 380mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
2021-06-29 ~ 2022-01-18 - FOLFIRI + bevacizumab
2021-05-13 ~ 2021-06-11 - FOLFIRI
[anemia]
Since 2023-02, the patient has been receiving FOLFIRI regimen. On 2023-08-06, there was an episode of grade 3 anemia (HGB < 8 g/dL) (another grade 3 anemia was recorded on 2023-04-03 with a HGB level of 7.6g/dL). To address the anemia, blood transfusions were administered on 2023-03-14, 2023-04-03, 2023-05-12, and 2023-08-06.
Starting from 2023-04-03, the dose of Irinotecan was reduced to 60% (300mg -> 180mg -> 175mg).
According to the PharmaCloud database, this patient has only received his medical needs from our hospital in the past 3 months, no medication reconciliation issues identified.
[exam findings]
[surgical operation]
[MedRec]
[radiotherapy]
[chemotherapy]
The package insert for Dicetel (pinaverium bromide) advises against oral ingestion or chewing. It is recommended to swallow the medication with a large glass of water during meals to prevent contact with the esophageal mucosa (risk of esophageal injury) and not be taken while lying down or before bedtime. This indicates that tube feeding is not recommended.
[MedRec]
[chemotherapy]
All repeat prescriptions from our endocrinologist, orthopedist, and cardiologist were added to the active medication list, with the exception of midorine. During this hospitalization, there is no evidence of symptomatic orthostatic hypotension in the HIS5 records, so no reconciliation issues were identified.
[MedRec]
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
This patient refilled Eurodin (estazolam) and Lexapro (escitalopram) on 2023-07-10 issued by our psychosomatic medicine department and these drugs have been included in the active medication list without a reconciliation issue found.
[fluconazole dosing for HD patients]
For patients undergoing intermittent (thrice weekly) hemodialysis, whether intravenous or oral fluconazole is used, the dosing should be administered three times a week after each dialysis session. No dosage adjustment is required for indication-specific loading/initial or maintenance doses recommended in the adult dosing section. However, it is important to administer maintenance doses only three times per week on dialysis days after the dialysis session.
[lab data]
[exam findings]
[MedRec]
[chemoimmunotherapy]
The patient recently renewed her repeat prescription for Diovan (valsartan) to manage her primary hypertension at a local pharmacy on 2023-07-19. This medication is currently listed in the active formulary, and no reconciliation issues have been identified.
The most recent medical image was scaned on 2023-05-05 (abdomen CT). An update may be beneficial to reassess the current disease status.
[exam findings]
[MedRec]
[medication reconciliation]
The patient was prescribed famotidine, cyanocobalamin, and betamethasone on 2023-07-28 for a 7-day duration at JingMei Hospital to address her malignant neoplasm of the small intestine. However, these medications are currently not included in the active medication list. It is advised to review whether they are still necessary for the patient’s current condition.
[exam findings]
[consultation]
[immunochemotherapy]
On 2023-06-10, our urologist wrote a 3-time refill prescription (valid for 84 days) for Harnalidge (tamsulosin) and Betmiga (mirabegron). Additionally, on 2023-06-12, our cardiac surgeon issued a 3-time repeat prescription (also valid for 84 days) for Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin). These medications have been included in the active medication list, and no reconciliation issues have been identified.
In accordance with the PharmaCloud database, this patient has only been a patient of our hospital for the last 3 months. In addition to our hemato-oncology department, our urologist prescribed Harnalidge (tamsulosin) and Betmiga (mirabegron) on 2023-06-10. In addition, our cardiac surgeon prescribed Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin) on 2023-06-12. These medications have been accurately added to the list of active medications and no discrepancies have been identified in the reconciliation.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[reconciliation]
Our hospital is the only medical provider for this patient according to the PharmaCloud database, no medication reconciliation issues identified.
[tube feeding]
Betmiga (mirabegron) is a long acting formulation, it is not recommended to crush or halve for tube feeding. As the effect of mirabegron 50mg is approximately equivalent to that of propiverine 30mg, it is recommended to switch to Urotrol (propiverine 15mg), 1# BID for tube feeding. Doxaben XL (doxazosin) is a sustained-release formulation. It is suggested to consider switching to Urief (silodosin) as an alternative to Doxaben.
[diagnosis] - 2023-04-06 admission note
[past history]
[allergy]
[family history]
There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.
[exam findings]
[consultation]
[chemoimmunotherapy]
Based on the PharmaCloud database, we see that the patient has only visited our hemato-oncology department in the last 3 months. As a result, no medication reconciliation issues are identified for this admission.
[exam findings]
[SOAP]
[surgical operation]
[chemotherapy]
Based on the PharmaCloud database, we see that the patient has only visited our hospital. No medication reconciliation issues are identified for this admission after reviewing HIS5 records..
On 2023-07-26, the serum magnesium level was measured at 1.5mg/dL, indicating a low value. As a result, it is advised to add magnesium supplementation for the patient.
[exam findings]
[MedRec]
[immunochemotherapy]
[reconciliation]
Our dermatologist prescribed a 7-day course of Compesolon (prednisolone), Xyzal (levocetirizine), Asthan (ketotifen), Pilan (cyproheptadine), and Topsym Cream (fluocinonide) for the patient’s severe itchy papules and plaques eruption over the trunk on 2023-07-20. However, these drugs are not currently included in the list of active medications. It is advisable to check whether the skin symptoms have improved before continuing or adjusting the treatment plan.
[lab data]
2023-07-19 HSV 1 IgM Negative NTU
2023-07-19 HSV 1 IgM Value 1.52 NTU
2023-07-19 HSV 2 IgM Negative NTU
2023-07-19 HSV 2 IgM Value 1.37 NTU
2023-07-19 HLA A-high 11:01
2023-07-19 HLA A-high 33:03
2023-07-19 HLA B-high 38:02
2023-07-19 HLA B-high 39:01
2023-07-19 HLA C-high 07:02
2023-07-19 HLA C-high -
2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DQ-high 03:03
2023-07-19 HLA DQ-high 05:02
2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DR-high 09:01
2023-07-19 HLA DR-high 14:54
[exam findings]
[MedRec]
[chemotherapy]
2023-07-19 - L-asparaginase 6000unit/m2 9540unit IM 1min
2023-07-10 - methotrexate 4600mg NS 250mL 24hr
2021-02-18
2021-01-14
2020-12-21
2020-11-27
2020-11-13
2020-10-06
2020-09-29
[deterioration in liver function; acetaminophen, Stronger Neo Minophagen C Injection]
In recent days, the patient has shown a significant increase in bilirubin and liver enzymes. After reviewing the drugs listed in the active medication, entecavir, furosemide, and acetaminophen are found to be associated with these symptoms according to the medication database. Since the VAS (visual analogue scale) has been recorded as 0 since 2023-07-29, it might be worth considering discontinuing acetaminophen. Additionally, please note that the Stronger Neo Minophagen C Injection will expire by the morning of 2023-08-01. If it is still required, please extend its use accordingly.
2023-07-31 Bilirubin total 14.51 mg/dL ** 2023-07-27 Bilirubin total
2.44 mg/dL *
2023-07-26 Bilirubin total 1.02 mg/dL
2023-07-24 Bilirubin total 0.70 mg/dL
2023-07-21 Bilirubin total 0.49 mg/dL
2023-07-19 Bilirubin total 0.51 mg/dL
2023-07-17 Bilirubin total 0.52 mg/dL
2023-07-15 Bilirubin total 0.59 mg/dL
2023-07-14 Bilirubin total 0.68 mg/dL
2023-06-27 Bilirubin total 0.31 mg/dL
2023-07-31 S-GPT/ALT 655 U/L 2023-07-27 S-GPT/ALT 309 U/L 2023-07-26 S-GPT/ALT 219 U/L 2023-07-24 S-GPT/ALT 161 U/L 2023-07-21 S-GPT/ALT 180 U/L 2023-07-19 S-GPT/ALT 162 U/L 2023-07-17 S-GPT/ALT 278 U/L 2023-07-15 S-GPT/ALT 541 U/L 2023-07-14 S-GPT/ALT 638 U/L 2023-07-13 S-GPT/ALT 412 U/L 2023-07-09 S-GPT/ALT 137 U/L 2023-06-27 S-GPT/ALT 63 U/L 2023-06-23 S-GPT/ALT 62 U/L 2023-06-18 S-GPT/ALT 46 U/L 2023-06-05 S-GPT/ALT 31 U/L 2023-06-03 S-GPT/ALT 26 U/L
[No specific preparation is described for Stronger Neo-Minophagen C Injection]
to primary nurse: After checking the Micromedex database, there is no available data on the compatibility of glycyrrhizinate monoammonium, the main ingredient in Stronger Neo-Minophagen C Injection. Additionally, the package insert for this medication does not provide specific instructions regarding the preparation prior to injection administration.
[teicoplanin 600mg from Q3D to QOD]
2023-07-19 Cre 1.47mg/dL, 57.5kg => CrCl 35mL/min. According to the Sanford Guide, teicoplanin in patients with CrCl 30 to 80, for complicated skin/soft tissue, pneumonia, complicated UTI: 6mg/kg QOD and for bone and joint infections, endocarditis: 12mg/kg QOD. It is recommended to increase the frequency from Q3D to QOD.
[leukopenia]
An episode of leukopenia was observed on 2023-07-19, 9 days after administration of 4600 mg MTX on 2023-07-10. The label for MTX includes a boxed warning regarding potential bone marrow, liver, lung, skin, and kidney toxicity, and patients should be monitored closely for such effects. Given the timing and characteristics of MTX, it cannot be ruled out that the leukopenia episode was due to MTX.
According to NHI reimbursement guidelines, short-acting G-CSF (e.g., filgrastim, lenograstim) may be used for patients with hematologic malignancies receiving intravenous chemotherapy, provided the patient meets this condition.
[MTX level follow-up. Leucovorin might begin 24 hr after the start of MTX]
Methotrexate 4600mg was administered on 2023-07-10, and leucovorin 150mg Q3H has been started since 2023-07-13. Follow-up methotrexate level has shown significant decrease and is now less than 10 umol/L.
It is recommended that rescue treatment following high-dose methotrexate starts with an initial dosage of around 15 mg (~10 mg/m2). This should begin 24 hours after the start of the methotrexate infusion and the treatment should continue Q6H for doses, until the MTX level drops below 0.05 micromolar.
The patient is adequately hydrated with normal saline and the urine is alkalinized with Rolikan (sodium bicarbonate).
[bedside visit]
I visited the patient at around 16:00 today. She mentioned that her throat was a bit sore, which could be due to mucositis. The addition of Nincort Oral Gel (triamcinolone acetonide) might help in relieving her symptoms.
[Covorin demand confirmation]
Today, during the UD (Unit Dose) vehicle preparing, it was discovered that the demand for Covorin (leucovorin 50mg) is 72 amps. At 13:25, I made a call to Dr. Wang QiQi to confirm the chief resident physician’s decision on the medication quantity.
[diagnosis] - 2023-03-13 admission note
[past history]
[family history]
[lab data]
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
[note]
Chemotherapy regimens for advanced esophagogastric cancer: Docetaxel, cisplatin, and fluorouracil (DCF) 2023-07-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F73324
Chemotherapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) 2023-03-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F120512
ref: Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-1957. doi:10.1016/S0140-6736(18)32557-1
This patient receives all medical care exclusively at our hospital and has appointments with both the hematology-oncology and endocrinology and metabolism departments. Medications prescribed by the endocrinology and metabolism department, including Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, were correctly documented on the active medication list. As a result, no medication reconciliation issues were identified.
{not completed}
[exam findings]
[consultation]
[MedRec]
[chemotherapy]
Episodes of anemia were evident according to the most recent lab results.
The most recent chemotherapy administration was initiated on 2023-06-30. Additionally, the patient experienced several GI tumor bleeding events since 2023-03 and received blood transfusions on the following dates: 2023-03-24, 2023-03-25, 2023-04-05, 2023-04-12, 2023-04-19, 2023-04-23, 2023-06-30, 2023-07-07, 2023-07-19, and 2023-07-24. Considering that both tumor bleeding and blood transfusions can affect HGB levels, it is difficult to conclusively attribute anemia solely to chemotherapy, and the potential impact of chemotherapy cannot be completely ruled out.
Studies indicate that patients with gastroenteropancreatic neuroendocrine carcinoma who receive cisplatin/etoposide treatment can have an Objective Response Rate (ORR) ranging from 14% to 67%, as stated in “Systemic Treatment of Gastroenteropancreatic Neuroendocrine Carcinoma. Curr. Treat. Options in Oncol. 22, 68 (2021).”
The CT scan on 2023-07-05 demonstrated stable disease for the neuroendocrine carcinoma of the pancreatic body and tail, following 3 cycles of the cisplatin/etoposide regimen. This might suggest that the disease could be developing some degree of resistance to the treatment.
After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.
The patient sought treatment for unspecified dermatitis at Huang ZhenXian Dermatology Clinic on 2023-05-08 and was prescribed tranexamic acid, betamethasone, prednisolone, and loratadine for a short duration of 3 days. Currently, no dermatitis-related symptoms are observed in the admission note or the active medical problem list. Therefore, no medication reconciliation issues are identified.
[exam findings]
[MedRec]
[consulation]
[radiotherapy]
[chemotherapy]
[tube feeding - Concor]
According to the manufacturer’s instructions for Concor (bisoprolol 5 mg tablets), it should be swallowed with a drink of water and not chewed. However, if the patient is receiving tube feeding, the Simple Suspension Method (SSM) can be used. This method involves dissolving the tablets in warm water for 5-10 minutes and then passing the solution through a feeding tube for administration. The Simple Suspension Method may be appropriate for administration of Concor tablets through a feeding tube.
[renal dosing Tapimycin from Q6H to Q8H]
Kidney function appears to be deteriorating in this patient. 2023-07-25 CrCl 27 mL/min.
When using Tapimycin (piperacillin 4g, tazobactam 0.5g) in patients with a CrCl between 20 and 40, if the intended dose is 4.5g Q6H infused over 30 minutes, then the recommended doses are either 4.5g Q8H or 3.375g Q6H, with the former being preferred.
A dose of 4 mg once daily is recommended when using Urief (silodosin 8 mg) in patients with a CrCl between 30 and 50.
[leukopenia and thrombocytopenia]
Bicytopenia (leukopenia and thrombocytopenia) is evident based on recent lab results after consecutive 5-day fluorouracil administration (for CCRT), which started on 2023-06-26 and 2023-07-14.
2023-07-25 WBC 0.16 x10^3/uL
2023-07-14 WBC 2.82 x10^3/uL
2023-07-05 WBC 6.47 x10^3/uL
2023-06-26 WBC 8.28 x10^3/uL
2023-06-13 WBC 9.43 x10^3/uL
2023-07-25 HGB 9.0 g/dL
2023-07-14 HGB 9.1 g/dL
2023-07-05 HGB 9.5 g/dL
2023-06-26 HGB 8.3 g/dL
2023-06-13 HGB 10.0 g/dL
2023-07-25 PLT 80 *10^3/uL
2023-07-14 PLT 301 *10^3/uL
2023-07-05 PLT 299 *10^3/uL
2023-06-26 PLT 340 *10^3/uL
2023-06-13 PLT 459 *10^3/uL
Blood transfusions are performed on 2023-05-27, 2023-06-01, 2023-06-26, 2023-07-14, 2023-07-25 and Granocyte (lenograstim 250ug) is to be administered since 2023-07-25 for consecutive 6 days. No issue with the use of G-CSF.
[ARBs Equivalent Dose Conversion]
This patient is currently self-administering Diovan (valsartan 40mg) once daily and the supply is almost exhausted. Upon checking, our hospital only carries a 160mg dosage, which is inconvenient to divide into quarters. However, Olmetec (olmesartan 20mg) or Blopress (candesartan 8mg) is an option, as it belongs to the class of angiotensin II receptor blockers (ARBs) just like valsartan. Considering that approximately 40 mg of valsartan is equivalent to 10 mg of olmesartan or 4 mg of candesartan, it may be advisable to prescribe Olmetec at a dose of 0.5 tablets or Blopress at a dose of 0.5 tablets per day as a suitable alternative.
Our dermatologist prescribed fusidic acid and doxycycline on 2023-07-04 and these drugs are integrated into the active medication list without reconciliation issues found
[to replace Forxiga with Jardiance]
[patient education: 5-FU]
[reconciliation]
[MedRec]
This patient has been regularly visiting multiple departments at our hospital and receiving several repeat prescriptions.
Cardiology prescribed the following medications: - Norvasc (amlodipine) - Syntrend (carvedilol) - Meletin (mexiletine) - Ulstop (famotidine) - Plavix (clopidogrel) - Urief (silodosin)
Endocrinology prescribed the following medications: - NovoRapid (recombinant insulin aspart) - Toujeo (insulin glargine) - Kentamin (vitamin B1, B6, B12) - Lipanthyl (fenofibrate) - Through (sennoside) - Tulip (atorvastatin)
Neurology prescribed the following medications: - Dipydidamole - Sketa (acetaminophen, chlorzoxazone) - Rivotril (clonazepam) - Neurontin (gabapentin)
Ophthalmology prescribed the following eye medications: - Combigan Eye Drops (brimonidine, timolol) - Vidisic Gel (carbomer) - Tears Naturale (hydroxypropyl methylcellulose, dextran 70)
All the oral drugs have been included in the active medication list, except for the eye medications. Please check if the patient still needs these eye medications.
[exam findings]
[chemotherapy]
[exam findings]
[chemoimmunotherapy]
atezolizumab 2023-05-15 https://www.uptodate.com/contents/atezolizumab-drug-information
Brand Names: Tecentriq
Pharmacologic Category
Dosing: Adult
[De-escalation of Cefepime]
Based on in-hospital stock, the only available third-generation oral cephalosporin is Ceficin (cefixime 100mg) at a recommended dosing frequency of 2# Q12H. As the patient’s laboratory data on 2023-07-24 showed normal values for creatinine and blood urea nitrogen (BUN), there is no need to adjust the dosage of Ceficin.
[diagnosis] - 2023-04-12 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[note]
TPF regimens for Neoadjuvant Chemotherapy (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11) - see No.701240721, with docetaxel 40mg/m2 and cisplatin 40mg/m2
Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-13 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438
Cycle length: Every 21 days for three cycles.
Regimen
In search for optimal induction chemotherapy for advanced nasopharyngeal cancer: Standard dosing of Docetaxel, Platinum, and 5-Fluorouracil (TPF) followed by chemoradiation. Published: 2023-02-02. https://doi.org/10.1371/journal.pone.0276651
[duplicated H2RA]
The concomitant use of histamine H2-receptor antagonists such as Stogamet (cimetidine 300mg) and Ulstop (famotidine 20mg) is generally not recommended. Both drugs work by reducing the production of stomach acid, and using them together may increase the risk of side effects. It is advisable to evaluate the need to use these two drugs together to ensure drug safety.
[diagnosis] - 2023-04-06 admission note
Malignant neoplasm of unspecified site of unspecified female breast
2023-03-17 discharged note
[past history] - 2023-03-15 admission note
[allergy]
[family history]
[exam findings]
[chemotherapy]
According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No medication reconciliation issues were identified during her current admission.
Recently, a noticeable increase in ALT, AST and bilirubin levels can be seen based on the weekly lab data.
2023-07-12 S-GPT/ALT 119 U/L
2023-07-05 S-GPT/ALT 129 U/L
2023-06-28 S-GPT/ALT 132 U/L
2023-06-21 S-GPT/ALT 145 U/L
2023-06-14 S-GPT/ALT 112 U/L
2023-06-07 S-GPT/ALT 53 U/L
2023-07-12 S-GOT/AST 431 U/L
2023-07-05 S-GOT/AST 279 U/L
2023-06-28 S-GOT/AST 180 U/L
2023-06-21 S-GOT/AST 169 U/L
2023-06-14 S-GOT/AST 115 U/L
2023-06-07 S-GOT/AST 66 U/L
2023-07-12 Bilirubin total 2.73 mg/dL
2023-07-05 Bilirubin total 1.90 mg/dL
2023-06-28 Bilirubin total 1.00 mg/dL
2023-06-21 Bilirubin total 0.56 mg/dL
2023-06-14 Bilirubin total 0.40 mg/dL
2023-06-07 Bilirubin total 0.34 mg/dL
Per UpToDate, Enhertu (trastuzumab deruxtecan) is linked to a raised serum alanine aminotransferase (34% to 53%), elevated serum alkaline phosphatase (22% to 54%), increased serum aspartate aminotransferase (35% to 67%), and elevated serum bilirubin (16% to 24%).
According to the Enhertu label, there are limited data available for patients with moderate hepatic impairment, and none for patients with severe hepatic impairment. Given that metabolism and biliary excretion are the primary elimination routes for the topoisomerase I inhibitor component (DXd) in Enhertu, caution should be exercised when administering Enhertu to patients with moderate or severe hepatic impairment. The package insert does not provide dose adjustment guidelines based on LFT readings. It might be suggested to temporarily withhold the drug until the drug is ruled out as the cause of deterioration of liver function.
[diagnosis] - 20230103 admission note
[present illness] - 20230103 admission note
[past history]
[Allergy]
[family history]
[lab data]
[exam findings]
[MedRec]
[consultation]
[chemoimmunotherapy]
Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients - 20230104 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients
2023-07-16 (D9) WBC level has risen to 1.64K/uL, the recovery is obvious and the CMV viral load test showed that no virus was detected on 2017-07-17 (today). So far so good.
After the transplant, the patient’s kidney function levels fluctuate up and down around the upper limits of the normal range. A slight elevation in serum Cre is observed on 2023-07-13 and is to be followed.
The LFT results showed a monotonic increase in bilirubin levels after the transplant, as the enzyme levels started to fall, it might be sufficient to observe for a short time, if bilirubin still remains high, then action might need to be taken. Mycamine (micafungin) is associated with hyperbilirubinemia (UpToDate: <15%).
[liver function]
It seems that the patient’s liver function has declined, as indicated by increased levels of ALT, AST, and bilirubin.
2023-07-09 S-GPT/ALT 174 U/L
2023-07-03 S-GPT/ALT 71 U/L
2023-06-25 S-GPT/ALT 50 U/L
2023-06-09 S-GPT/ALT 38 U/L
2023-06-02 S-GPT/ALT 29 U/L
2023-05-25 S-GPT/ALT 27 U/L
2023-07-09 S-GOT/AST 101 U/L
2023-07-03 S-GOT/AST 43 U/L
2023-06-25 S-GOT/AST 40 U/L
2023-06-09 S-GOT/AST 29 U/L
2023-06-02 S-GOT/AST 22 U/L
2023-07-09 Bilirubin direct 0.43 mg/dL
2023-07-03 Bilirubin direct 0.16 mg/dL
2023-06-25 Bilirubin direct 0.13 mg/dL
2023-07-09 Bilirubin total 1.34 mg/dL
2023-07-03 Bilirubin total 0.63 mg/dL
There are several drugs on the patient’s active list that could potentially contribute to the decline in liver function. These include:
Given that another anti-HBV drug Baraclude (entecavir) can also lead to increased serum alanine aminotransferase levels (>5 x ULN: 11% to 12%; >10 x ULN and >2 x baseline: 2%), substituting tenofovir alafenamide with entecavir is not advised at present time. Similarly, another antifungal medication micafungin can lead to an increased serum alkaline phosphatase level (3% to 6%).
Considering the recent dosage increase of BaoGan (silymarin) on 2023-07-09 from 1# TID to 2# TID, rechecking the liver function tests in 2 days could be a practical strategy.
[renal function]
Aside from a slightly elevated BUN, decreasing serum creatinine and increasing eGFR suggest an improvement in the patient’s renal function. The CrCl has increased to 44 mL/min.
2023-07-09 Creatinine 1.22 mg/dL
2023-07-03 Creatinine 1.40 mg/dL
2023-06-25 Creatinine 1.76 mg/dL
2023-07-09 eGFR 61.38
2023-07-03 eGFR 52.37
2023-06-25 eGFR 40.21
2023-07-09 BUN 26 mg/dL
2023-07-03 BUN 28 mg/dL
2023-06-25 BUN 25 mg/dL
If the CrCl remains above 50 mL/min stably for several days and no further decline is expected, the dose of levofloxacin could optionally be increased to 750mg daily. In addition, the fluconazole dose could optionally be increased to 2# QD once it has been determined that it is not the cause of the deterioration in liver function.
[myeloablative conditioning regimen effect follow-up]
The BuCyE regimen was initiated on 2023-06-30, and there is a notable reduction in WBC, HGB, and PLT levels, which indicates that the regimen is taking effect.
2023-07-07 WBC 0.71 x10^3/uL
2023-07-05 WBC 3.07 x10^3/uL
2023-07-03 WBC 3.46 x10^3/uL
2023-06-25 WBC 5.39 x10^3/uL
2023-07-07 HGB 9.3 g/dL
2023-07-05 HGB 11.6 g/dL
2023-07-03 HGB 12.1 g/dL
2023-07-07 PLT 33 x10^3/uL
2023-07-05 PLT 67 x10^3/uL
2023-07-03 PLT 80 x10^3/uL
[renal function follow-up]
[dosage reviewed for current renal function level]
[pharmacist shift handover to chemotherapy preparation room]
Stem Cell Infustion Date D0: 2023-07-07 (tentative)
Drug - Dose - Infusion - Frequency - Duration - Date busulfan - 3.2mg/kg - 3hr - QD - D-7 ~ D-5 - 2023-06-30 ~ 2023-07-02 etoposide - 400mg/m2 - 6hr - QD - D-5 ~ D-4 - 2023-07-02 ~ 2023-07-03 cyclophosphamide - 50mg/m2 - 4hr - QD - D-3 ~ D-2 - 2023-07-04 ~ 2023-07-05
[Recommended Dose Adjustments for the BuCyE Conditioning Regimen and Associated Premedication]
2023-06-25 serum Cre 1.76mg/dL, age 76 => CrCl 30mL/min; height 162cm, weight 60kg => BMI 22.9kg/m2, BSA 1.64m2; 2023-06-25 S-GPT/ALT 50U/L, S-GOT/AST 40U/L, DBI/TBI 18.31%.
For BuCyE conditioning regimen, dose adjustment recommendation for the scheduled ASCT in this impaired renal function patient
For premedication
[Preparation and Administration of Mesna]
[past history]
[lab data]
2023-06-28 HIV Ab-EIA Nonreactive
2023-06-28 Anti-HIV Value 0.09 S/CO
2023-06-26 MTBC PCR DETECTED CFU/ml
2023-06-26 MTBC PCR Value 10000 - 100000 CFU/ml
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[tube feeding]
For patients on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking the capsule open and pouring the small granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be administered through the feeding tube. Note that these granules should not be crushed or chewed, and the prepared solution should be used immediately after it’s prepared.
[reconciliation]
According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No discrepancies or issues were identified during the medication reconciliation process for this patient during his current admission.
[assessment]
It appears that the patient’s renal function deteriorated last weekend. 2023-07-15 CXR showed ground-glass opacities in both lungs. CRP 13.8 mg/dL. There is a high incidence of AKI in patients hospitalized for CAP. It is advisable to be alert for the prevention and early detection of AKI in CAP patients. ref: Incidence and Risk Factors of Acute Kidney Injury in Patients Hospitalized with Pneumonia: A Prospective Observational Study. Med J Islam Repub Iran. 2021;35:150. Published 2021 Nov 10. doi:10.47176/mjiri.35.150
2023-07-15 Creatinine 1.76 mg/dL
2023-07-06 Creatinine 1.08 mg/dL
2023-07-03 Creatinine 1.05 mg/dL
2023-07-15 eGFR 43.10
2023-07-06 eGFR 75.73
2023-07-03 eGFR 78.23
The current dosage of Tapimycin (peperacillin 4g, tazobactam 0.5g) at 4.5g Q8H is still within a reasonable range, considering the patient’s current renal function.
In patients who are on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking open the capsule and pouring the tiny granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be delivered via the feeding tube. Do bear in mind that these granules shouldn’t be crushed or chewed, and the prepared solution must be used right after its preparation.
From 2023-03-28 to 2023-06-16, the patient has experienced significant weight loss, dropping from 53.1kg to 41.6kg. This indicates a loss of over 10kg within a span of approximately 2.5 months. A consultation with a dietitian took place on 2023-05-19. However, cachexia remains a current health issue for this patient. The patient is currently on tube feeding and is also taking the progesterone analogue megestrol without an issue. Glucocorticoids could potentially improve the patient’s appetite to a similar extent as the progesterone analogues. However, considering the potential for toxicities and decreased effectiveness with prolonged use, the application of glucocorticoids as an appetite stimulant is typically reserved for individuals with an estimated life expectancy ranging from a few weeks to a couple of months. Consequently, the use of glucocorticoids is not advised at this time.
The patient’s renal function markers continue to be elevated, so hydration has been administered (NS 500mL Q8H currently). The TPR panel reveals that the patient was experiencing tachycardia (122/min), tachypnea (21/min), and potentially inadequate SpO2 (92%), alongside a relatively low blood pressure reading (81/52 mmHg). Close monitoring is necessary in this case.
[tube feeding]
[exam findings]
[MedRec]
2023-04-26 ~ 2023-04-29 POMR Neurosurgery
2023-04-18 SOAP Hemato-Oncology
2023-04-11 ~ 2023-04-14 POMR Metabolism and Endocrinology (not completed)
2023-02-15 SOAP Hemato-Oncology
2022-12-20 SOAP Hemato-Oncology
[surgical operation]
[chemotherapy]
2023-07-03 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor)
2023-05-23 - FOLFOX @ Thailand
2023-05-09 - FOLFOX @ Thailand
2023-04-25 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-03-28 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-03-14 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-03-01 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-02-15 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)
2023-01-16 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)
[reconciliation]
The patient is not from the local area, so no records are available in the PharmaCloud database.
On 2023-05-03, our endocrinologist prescribed Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). On the same day, our neurosurgeon prescribed Keppra (levetiracetam), Neurontin (gabapentin), Norvasc (amlodipine), and Tulip (atorvastatin). These prescriptions, which are valid for 70 days, were added to the patient’s current medication list with no discrepancies identified during medication reconciliation.
[assessment]
A recent lab reading taken on 2023-07-11 revealed a significantly elevated serum glucose level of 253mg/dL, despite the administration of four antiglucemic agents - Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). It would be advisable to ensure regular monitoring of the patient’s blood sugar levels, and these readings should be displayed in the TPR panel.
[reconciliation]
[bedside visit, patient education]
[exam findings]
[consultation]
[chemotherapy]
G-CSF (filgrastim) 150ug
WBC
After reviewing the PharmaCloud database, no reconciliation issues were found.
[exploring CNS involvement]
An increased level of LDH is more common seen in patients with AML involving the CNS. Given that this patient was admitted with symptoms of dizziness and tinnitus, it could be worthwhile to conduct further investigations.
[exam findings]
[consultation]
[chemotherapy]
[exam findings]
[MedRec]
[consultation]
[chemoimmunotherapy]
Granocyte (lenograstim) 250mg SC
lab WBC
[note]
It appears that the approximate cycled trough WBC count occured around one week after the administration of single bleomycin agent, the G-CSF administration might follow this pattern.
The AFP/beta-HCG/LDH tests might be conducted again in December 2022 to make the monitor frequency not fall below two months. (There were still superior mediastinal widening and an enlarged Lt hilum on the CXR of 2022-11-30)
Pulmonary fibrosis is the most severe toxicity associated with bleomycin. The most frequent presentation is pneumonitis occasionally progressing to pulmonary fibrosis. Its occurrence is higher in elderly patients and in those receiving more than 400mg total dose, but pulmonary toxicity has been observed in young patients and those treated with low doses.
The primary chemotherapy regimen for germ cell tumors could be BEP, which consists of the following components (NCCN).
AST, ALT, Cre, and eGFR (2022-10-19) did not exhibit abnormalities, therefore no dose adjustment would be required for the BEP regimen based on pharmacokinetics.
The dose used is slightly lower than that recommended by the NCCN (currently: 80mg/m2 of etoposide, 15mg/m2 of cisplatin. NCCN: 100mg/m2, 20mg/m2). Given that the patient’s performance status scale is ECOG 0, it might be an option to upgrade the dose to meet the guideline to obtain more expected effects if no other considerations exist.
(not completed)
[exam findings]
[chemotherapy]
[reconciliation]
This patient intermittently visits a local ophthalmology clinic due to symptoms in his left eye. His most recent visit was on 2023-06-30, and the prescription given, which was valid for 3 days, has now expired. Please decide whether to refer him to our hospital’s ophthalmology department based on his current clinical condition.
[MedRec]
Recent lab data
Elevated serum glucose. This patient has type 2 DM and CVD, SGLT2i might be a choice to protect heart while lowering blood sugar.
SGLT2i such as empagliflozin, dapagliflozin, canagliflozin are available in stock could be prescirbed if UTI is unlikely.
[chemotherapy]
[exam findings]
[consultation]
[radiotherapy]
[chemotherapy]
The patient previously visited WanFang Hospital on 2023-06-02 for treatment of hemorrhoids and was given a 14-day supply of medication, which has now expired. As the patient did not report any problems related to his hemorrhoids at the time of his current admission, no concerns were identified during the medication reconciliation process.
Continuing from the previous pharmacist note, confirm that Baraclude (entecavir 0.5 mg) 1# QDAC has been prescribed. There are no other medication-related problems at this time.
Lab 2023-06-16 Anti-HBc positive. If immunosuppressive chemotherapy is to be used, it is advisable to use either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD as a precaution, at least during the course of chemotherapy. This would help protect against the potential reactivation of HBV infection by chemotherapy.
[exam findings]
[consultation]
[chemotherapy]
This patient just refilled a prescription for Harnalidge (tamsulosin) on 2023-07-06 for his benign prostatic hyperplasia with lower urinary tract symptoms. This drug has been included in the active medication list with no reconciliation issues identified.
[exam findings]
[MedRec]
[chemotherapy]
Our otorhinolaryngologist prescribed a regimen on 2023-07-05 that included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Shitan (bromhexine), Acetal (acetaminophen), Ulstop (famotidine), and Nincort Oral Gel (triamcinolone). Additionally, our endocrinologist provided prescriptions for Crestor (rosuvastatin), Diovan (valsartan), Suwell (aluminum hydroxide, magnesium hydroxide, simethicone), Bokey (aspirin), Norvasc (amlodipine), and Lipanthyl (fenofibrate) on 2023-06-29. All these medications are currently present on the patient’s active medication list, with no detected issues relating to medication reconciliation.
Our otorhinolaryngologist issued a prescription on 2023-06-07, which included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Broen-C (bromelain, L-cysteine), Tramacet (tramadol, acetaminophen), and Nincort Oral Gel (triamcinolone) to address the patient’s ENT symptoms. The prescription was given a 14-day duration and is currently still valid. However, none of these drugs appear on the active medication list. Please verify if the related symptoms have resolved, which would explain the absence of these medications from the active list. Thank you!
Laboratory data show that the patient experienced an episode of leukopenia with a WBC count of 2.39K/uL on 2023-05-24, one week after starting his 1st dose of the current treatment regimen on 2023-05-17. Granocyte (lenograstim 250ug) was administered for 3 consecutive days (from 2023-05-24 to 2023-05-26) to increase the WBC count. The 2nd administration of the regimen began on 2023-06-12, maintaining the same dose level as the first cycle. Therefore, a similar incidence of leukopenia might be expected and prophylactic use of G-CSF may be considered to mitigate this potential risk.
[lab data]
2023-04-07 Anti-HBc Reactive
2023-04-07 Anti-HBc-Value 6.97 S/CO
2023-04-07 Anti-HBs 49.82 mIU/mL
2023-04-07 SCC 1.9 ng/mL
2023-04-07 CEA 0.82 ng/mL
2023-03-29 RPR/VDRL Nonreactive
2023-03-29 HBsAg Nonreactive
2023-03-29 HBsAg (Value) 0.44 S/CO
2023-03-29 Anti-HCV Nonreactive
2023-03-29 Anti-HCV Value 0.09 S/CO
2023-03-29 HIV Ab-EIA Nonreactive
2023-03-29 Anti-HIV Value 0.06 S/CO
[exam findings]
[consultation]
[MedRec]
[chemotherapy]
TPF regimen in in-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2023-03-31)
Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694
Cycle length: Every 21 days for 4 cycles.
Regimen
Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694
Cycle length: Every 21 days for 3 cycles.
Regimen
[reconciliation]
According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.
After examining the PharmaCloud medical records, it’s evident that this patient has been solely receiving care from our hospital over the past three months. All prescriptions have been issued by our outpatient and inpatient hemato-oncology services. Consequently, no medication reconciliation issues have been identified.
The docetaxel/cisplatin/fluorouracil regimen was administered to the patient on 2023-04-24 and 2023-06-09. Historical lab data showed a drop in WBC count below 1000/uL from 2023-05-01 to 2023-05-05, indicating leukopenia roughly 1 to 2 weeks after the initial round of the regimen. A total of 6 doses of Granocyte (lenograstim 250ug) were administered daily between 2023-05-01 and 2023-05-07. Given that the seconnd round of the regimen started on 2023-06-09 with the same dosage as the first, it is plausible that another leukopenia episode could occur about one week after treatment. Therefore, a prophylactic administration of G-CSF post-chemotherapy might be considered.
{metastatic renal cell carcinoma} (not completed)
[history]
[exam findings]
[MedRec]
[immunotherapy]
2023-07-10 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-06-13 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-05-12 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-04-14 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-03-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-02-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-04-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-03-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-03-01 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-02-09 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-01-18 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2021-12-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2021-11-30 - pembrolizumab 200mg NS 100mL 1hr
2021-11-05 - pembrolizumab 200mg NS 100mL 1hr
2021-10-15 - pembrolizumab 200mg NS 100mL 1hr
2021-09-08 - pembrolizumab 200mg NS 100mL 1hr
2020-10 erlotinib + bevacizumab followed with nivolumab + carboplatin.
[availability of entrectinib and/or alectinib]
According to the latest National Health Insurance (NHI) Drug Reimbursement Guidelines (version dated 2023-05-23), Rozlytrek (entrectinib) is only covered when used alone in adults with ROS-1 positive locally advanced or metastatic NSCLC. Alecensa (alectinib) is covered only for first-line treatment of ALK-positive advanced NSCLC. Both are not covered for papillary renal cell carcinoma.
Both Rozlytrek (entrectinib 200mg/capsule) and Alecensa (alectinib 150mg/capsule) are available in the hospital’s inventory, so no prior authorization is required (no temporary purchase procedure is necessary). The out-of-pocket cost for the former is 1802.5 TWD (NHI price 1530 TWD) and for the latter 487.5 TWD (NHI price 390 TWD).
{autologous Peripheral Blood Stem Cell Transplantation}
chemotherapy with Mabthera on 12/27,Etoposide 500mg/m2 total given 963mg Q12H on 12/28-30 followed by PBSC harvest,GCSF 300mcg QD on 12/31-1/14.Port-A removal on 2022/1/14.
[chemoimmunotherapy]
2023-07-07 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)
2023-05-30 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)
2023-05-08 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)
2023-04-17 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)
2022-08-17 - busulfan 3.2mg/kg 260mg 2hr D1-3 + etoposide 400mg/m2 567mg 1hr D3-4 + cyclophosphamide 50mg/kg 4000mg D5-6 (BuCyE)
2021-12-27 - rituximab 375mg/m2 720mg 8hr D1 + etoposide 500mg/m2 963mg 4hr D2-4
2021-11-19 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE) followed by PBSC harvest, GCSF 300mcg QD on 2021-12-31 ~ 2022-01-14.
2021-10-27 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)
2021-10-06 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)
2019-04-03 ~ 2019-09-07 - ESHAP 7 cycles
2017-12-30 ~ 2018-06-01 - ABVD
The patient underwent an autoPBSCT procedure in August 2022, almost a year ago. Based on the Guidelines for Vaccination of Adult BMT Patients provided by Stanford Healthcare, the proposed vaccination schedule is as follows (ref: https://med.stanford.edu/content/dam/sm/bugsanddrugs/documents/clinicalpathways/SHC-Vaccination-BMT.pdf):
According to the guideline, most vaccinations are started 12 months after transplant, so it may be an appropriate time to start planning the vaccination schedule for this patient. This can help reduce the risk of infection and promote the patient’s overall health and recovery.
[preparation and administration of mesna]
[Teicoplanin Dose]
{Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC}
[lab data]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
2023-06-12 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus, reduced Oxa)
2023-05-17 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus for 20230515 WBC 2.9K)
2023-04-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX)
2023-03-31 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX) (20230419 WBC 2.27K)
2023-02-21 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2023-02-07 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2023-01-17 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-12-29 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-12-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-11-28 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-11-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-10-24 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-10-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-09-16 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-08-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-08-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-08-01 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-07-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-06-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-06-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-05-25 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-05-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-04-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-03-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-03-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-02-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-02-11 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-01-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-01-03 - irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2021-12-20 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)
2021-11-23 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)
2021-11-10 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)
2021-10-22 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-10-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-09-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-09-01 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-08-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-08-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-07-16 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFOX, Q2W)
2021-07-02 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 3900mg 46hr (FOLFOX, Q2W)
Based on the PharmaCloud database, it’s evident that this patient has been receiving outpatient and inpatient medical services exclusively at our hospital for the past three months. As per the records, our Cardiologist prescribed a refillable order of Concor (bisoprolol), Doxaben (doxazosin), Forxiga (dapagliflozin), Hyzaar (losartan, hydrochlorothiazide), Pravafen (pravastatin, fenofibrate), and Zandip (lercanidipine) on 2023-04-12. These medications are accurately reflected in the patient’s active medication list. Consequently, no medication reconciliation issues have been identified.
Lab data showed a worsening liver function. The patient is currently prescribed OxyNorm (oxycodone 5mg). The package insert for OxyNorm indicates that plasma concentrations may increase in patients with mild to moderate renal impairment and mild hepatic impairment. Therefore, a conservative approach should be taken when adjusting the dosage. For patients with hepatic impairment, the starting dose should be one third to half of the usual initial dose, followed by careful dose adjustment. It is worth noting that 10 mg oral oxycodone is equivalent to 20 mg oral morphine. There is no evidence to suggest that the current dosage of 5mg Q6H is inappropriate. However, close monitoring for potential adverse reactions is recommended.
The most recent lab data (2023-05-16) shows a direct bilirubin level of 0.26mg/dL and an AST level of 45U/L, both slightly exceeding the upper limit of normal. This could indicate potential liver insufficiency. Since fentanyl is primarily metabolized into inactive metabolites in the liver, hepatic insufficiency could potentially slow its elimination. Therefore, patients with impaired liver function using the fentanyl transdermal patch should be monitored for signs of toxicity, and the dose might need to be reduced if necessary. Please update the patient’s liver function readings. If mild to moderate hepatic impairment is confirmed, then the dose is adviced to be reduced by 50%. It’s not recommended to use the fentanyl patch in patients with severe hepatic impairment.
The patient was treated with FOLFIRI from 2021-08 to 2022-09, then with FOLFOX from 2022-10 to 2023-02, and then with FOLFIRINOX since 2023-03. However, due to the obvious upward trend of tumor markers, it is possible that the disease may have developed further resistance to these changed regimens.
The current FOLFIRINOX regimen is being administered without a bolus of 5-FU and with a reduced dose of oxaliplatin, due to observed adverse events and/or patient’s performance status. This is considered an appropriate adjustment and there are no issues identified with this approach.
After image studies in early Oct 2022 revealed a number of lesions with a mild increase in size, and multiple bone metastases in progress, the regimen was changed from FOLFIRI to FOLFOX.
In the past three months, certain tumor markers have been elevated.
As SBP highly fluctuated between 136 and 231 under treatment with (patient-carried medication) Concor (bisoprolol), Zanidip (lercanidipine) and Hyzaar (losartan + hydrochlorothiazide), please monitor this closely. The drug Atanaal (nifedipine 5mg) 1# PRNQ6H might be considered in case where the blood pressure exceeds 200mmHg.
SBP flucturated at a wide range 136~231mmHg under patient-carried antihypertensive agents Concor (bisoprolol) and Hyzaar (losartan + hydrochlorothiazide), please keep a closer eye on it.
Pre-prandial blood sugar levels were higher than 170mg/dL for 2 days; metformin 500mg BID is recommended.
[lab data]
2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.28 S/CO
2023-06-07 Anti-HBc Reactive
2023-06-07 Anti-HBc-Value 7.60 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 Anti-HBs 4.14 mIU/mL
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
According to the PharmaCloud database, this patient sporadically visits local clinics for his sleep disorder, chest pain, and acute upper respiratory infections. He has been given prescriptions with a duration of only three days, all of which are now invalid. The patient has sought medical attention multiple times due to his sleep disorder, and Eurodin (estazolam) is listed among his active medications. No reconciliation issues have been identified.
Mild hyponatremia was observed in the patient on 2023-07-05, with a serum sodium level of 131 mmol/L. The planned administration of furosemide on 2023-07-06 (concurrent with the PF regimen) may exacerbate this condition, as furosemide may cause increased sodium excretion. Please continue to monitor the patient’s sodium levels closely to determine if further intervention is needed.
[lab data]
2023-06-27 Urine-Creatinine 105.41 mg/dL
2023-06-27 U-Cr (24hr) 1633.9 mg/kg/24 hr
2023-06-27 Total Volume(24hr) 1550 mL
2023-06-27 C.C.R. 120.7 mL/min
2023-06-20 EBV DNA PCR 159 copies/mL
2023-06-14 Anti-HBc Nonreactive
2023-06-14 Anti-HBc-Value 0.06 S/CO
2023-06-14 Anti-HBs 0.40 mIU/mL
2023-06-07 RPR/VDRL Nonreactive
2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.27 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 HIV Ab-EIA Nonreactive
2023-06-07 Anti-HIV Value 0.07 S/CO
2021-08-17 RPR/VDRL Nonreactive
[exam findings] (not completed)
[consultation]
[chemotherapy]
[bedside visit: poor appetite. patient education: docetaxel, cisplatin, fluorouracil]
[lab data]
2021-11-10 ROS1 FISH NOT detected
2021-11-09 EGFR G719X not detected
2021-11-09 EGFR Exon19 del detected
2021-11-09 EGFR S768I not detected
2021-11-09 EGFR T790M not detected
2021-11-09 EGFR Exon20 ins not detected
2021-11-09 EGFR L858R not detected
2021-11-09 EGFR L861Q not detected
2021-11-08 PD-L1 (28-8) TC <1%
2021-11-03 PD-L1 (22C3) TPS<1%
2021-11-03 ALK IHC Negative
2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.05 Ratio
2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.08 Ratio
2021-10-25 Mycoplasma IgM Negative Index
2021-10-25 Mycoplasma IgM Value 0.1 Index
2021-10-22 Anti-HBs 11.64 mIU/mL
2021-10-22 HBsAg Nonreactive
2021-10-22 HBsAg (Value) 0.47 S/CO
2021-10-22 Anti-HBc Nonreactive
2021-10-22 Anti-HBc-Value 0.31 S/CO
2021-10-22 Anti-HCV Nonreactive
2021-10-22 Anti-HCV Value 0.04 S/CO
2021-10-22 HIV Ab-EIA Nonreactive
2021-10-22 Anti-HIV Value 0.06 S/CO
[exam findings] (not completed)
[MedRec]
[treatment]
2021-11-25 ~ undergoing - Tagrisso (osimertinib 80mg) 1# QD
2021-11-11 ~ 2021-11-24 - Iressa (gefitinib 250mg) 1# QD
I visited the patient around 11:10 on 2023-07-05 with the osimertinib medication pamphlet. The patient was lying in bed and his son was on a bench against the wall.
I explained to the patient and his son that he has been using osimertinib for a relatively long period of time and based on the pamphlet, I described the potential side effects to watch for during the use of this drug. The patient’s son said that the main issue was digestive tract symptoms, but other than that, everything else felt fine, and the tumor has been controlled for a good period of time, they are still satisfied with the efficacy. I left the contact information for the hospital’s pharmacy counseling window, so the patient and his family can call when needed.
[exam findings]
[MedRec]
[consultation]
As per the PharmaCloud database, this patient frequently visits RenJi Hospital (last visit on 2023-06-19) and routinely refills his prescription at a local pharmacy. The prescription includes sennoside, ubidecarenone, bisoprolol, valsartan, pitavastatin, levothyroxine, alprazolam, carbinoxamine, and dextromethorphan.
Except for carbinoxamine (a first-generation antihistamine used to treat allergic rhinitis and vasomotor rhinitis), all other drugs are included in the active medication list. However, no current diagnosis or active medical problems relating to allergic rhinitis or vasomotor rhinitis have been identified. Thus, there is no evidence of discrepancies in medication reconciliation.
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
Neoadjuvant Chemotherapy regimen in In-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2022-02-11).
Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694
Cycle length: Every 21 days for three cycles.
Regimen
Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694
Cycle length: Every 21 days for four cycles.
Regimen
[macrocytic anemia]
Macrocytic anemia is present. Common etiologies include vitamin B12 and/or folate deficiency. Supplementation might be considered.
According to the PharmaCloud database, all of this patient’s prescribed medications for the past 3 months have been provided exclusively by our hospital. There are no identified medication reconciliation issues.
The leukocytosis seems to be improving as the patient’s WBC count is nearing ULN. The medications recently used, which include esomeprazole, entecavir, and megestrol, have been reviewed, but none of them are known to significantly affect the WBC count. At the moment, there don’t seem to be any medication-related problems associated with this issue.
Hypomagnesemia has been noted. This might be due to the use of the TPF regimen, which contains cisplatin, and/or the PPI, esomeprazole. During the regimen administration and hospital stay, the patient receives magnesium supplements. Given that hypomagnesemia has been persistent for several months, it may be beneficial to consider magnesium supplementation upon discharge.
[present illness] - 2023-03-20 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
2023-08-31 - FOLFOX
2023-08-04 - FOLFOX
2023-07-20 - FOLFOX
2023-06-29 - FOLFOX
2023-06-07 - FOLFOX
2023-05-15 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 760mg NS 250mL 2hr + fluorouracil 2800mg/m2 3735mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)
2023-04-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)
2023-03-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 775mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)
[note]
Refillable prescriptions for patients with chronic illnesses - ref: https://www.nhi.gov.tw/Glossary/Glossary.aspx?page=6
Our neurologist prescribed Saline (nicametate) on 2023-07-05, our endocrinologist prescribed Eltroxin (levothyroxine), and our urologist prescribed Betmiga (mirabegron), Eurodin (estazolam), Harnalidge (tamsulosin), Minirin (desmopressin), Norvasc (amlodipine), and Uretropic (furosemide) on 2023-07-08. These drugs are included in the list of active medications and reconciliation issues found.
[exam findings]
{metastatic breast cancer}
[exam findings]
[counsultation]
[immunochemotherapy]
[underdose] (not posted)
Enhertu 5.4mg/kg
[reconciliation]
[patient education]
[exam findings]
[chemotherapy]
2023-06-27 G-CSF (filgrastim 150ug) SC ST 2023-06-21 Granocyte (lenograstim 250ug) SC QD 3D
The pathology results from the breast biopsy performed on 2023-03-10 confirmed that the patient has triple-negative breast cancer (TNBC) with HER2-low characteristic (ER negative, PR negative, and Her2/neu score=1+).
Following this diagnosis, the patient underwent four cycles of liposomal doxorubicin with cyclophosphamide (AC) on 2023-03-21, 2023-04-12, 2023-05-03, and 2023-05-31. Docetaxel was then administered on 2023-06-21.
Leukopenia episodes were observed on the 20th day after the 3rd AC administration and the 6th day after the 1st docetaxel administration, with WBC levels marked with an asterisk (*) representing WBC < 2K/uL and double asterisks (**) representing WBC < 1K/uL.
To manage the episodes of leukopenia, filgrastim 150ug was given on 2023-06-27 and lenograstim 250ug was given consecutively for 3 days starting from 2023-06-21. Following these interventions, the patient’s WBC level has begun to show signs of improvement. Regular monitoring is essential to ensure this upward trend continues and to ensure the patient’s safety during further chemotherapy treatments.
The NHI in Taiwan approves the use of G-CSF for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL after chemotherapy. As the patient meets these criteria, the use of G-CSF is covered by NHI.
The patient received G-CSF with the chemotherapy regimen on 2023-06-21. For primary and secondary prophylaxis, G-CSF administration should typically begin 24 to 72 hours after completion of chemotherapy.
If the current chemotherapy regimen becomes less effective, Enhertu (fam-trastuzumab deruxtecan-nxki) may be used. This medicine is indicated for adult patients with unresectable or metastatic HER2 low (IHC 1+ or IHC 2+/ISH-) breast cancer who have received prior chemotherapy in the metastatic setting or who have experienced disease recurrence within six months of completing adjuvant chemotherapy. However, Enhertu is currently not covered by NHI in Taiwan.
[exam findings]
[consultation]
[immunochemotherapy]
Regimen Reference Order - BRST - DCH — ref: https://www.cancercare.mb.ca/export/sites/default/For-Health-Professionals/.galleries/files/treatment-guidelines-rro-files/regimen-reference-orders/breast/BRST-DCH.pdf — Updated: June 14, 2023
The patient received two cycles of the DCH regimen on 2023-06-06 and 2023-06-27. However, lab data shows that there was already a noticeable decrease in HGB levels before the initiation of the regimen, with the lowest record on 2023-05-22 at 5.6g/dL. Subsequently, multiple blood transfusions were conducted on 2023-05-22, 2023-06-05, and 2023-06-27.
Trastuzumab has been associated with a low occurrence of anemia, affecting approximately 4% of patients, with less than 1% experiencing a severe (grade 3) form, according to UpToDate. However, both docetaxel and carboplatin, which are part of the patient’s treatment regimen, are known to significantly increase the risk of anemia. Docetaxel can cause anemia in 65% to 97% of patients, with 8% to 9% experiencing severe anemia (grades 3/4). Carboplatin can cause anemia in a wide range of 21% to 90% of patients. Therefore, these drugs could be contributing to the patient’s current anemia.
MCV is at the lower end of the normal limit, and both MCH and MCHC are below the lower limit of normal, suggesting possible iron deficiency. This is further supported by the ferritin level measured on 2023-05-24, which was significantly below the lower limit of normal. It may be necessary to further investigate and address this possible iron deficiency.
[exam findings]
[consultation]
[chemotherapy]
[exam findings]
[immunochemotherapy]
The patient’s medical history, as recorded in the HIS5 database, shows previous episodes of leukopenia and thrombocytopenia in 2018-01. No chemotherapy was administered at that time.
More recently, in mid to late May 2023, the patient was diagnosed with SCC of the left tongue margin. The patient then received TPF chemotherapy on 2023-06-09 and a combination of TPF and cetuximab on 2023-06-19. Leukopenia, defined here as a WBC count of less than 3K/uL, was observed on 2023-06-16. To treat this, 3 doses of Granocyte (lenograstim 250ug) were administered on 2023-06-16, 2023-06-17, and 2023-06-21.
Given that the WBC count prior to the 2nd dose of TPF was higher than that prior to the 1st dose, and given that G-CSF was administered 2023-06-21 morning, the likelihood of severe leukopenia following the 2nd round of chemotherapy is expected to be reduced. However, the patient’s blood counts should continue to be monitored closely.
[reconciliation]
{esophageal SCC moderately differentiated T3N2M1 with lung mets}
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient has been prescribed Bafen (baclofen 5mg) 1# PRNQ12H for hiccups. Metoclopramide is also included in the active medication list. Both baclofen and metoclopramide are regarded as first-line therapy for hiccups. However, it’s advisable to note that there have been numerous cases reported in the literature indicating neurotoxicity due to oral baclofen accumulation in adult patients with varying levels of renal impairment. Additionally, abrupt discontinuation of oral baclofen has been linked to altered mental status. While the current dosage seems unlikely to cause these adverse reactions, it’s worth mentioning as a precaution.
[lab data]
2023-06-16 Anti-HBc Reactive
2023-06-16 Anti-HBc-Value 8.30 S/CO
2023-06-16 Anti-HBs 0.91 mIU/mL
2023-06-16 Anti-HCV Nonreactive
2023-06-16 Anti-HCV Value 0.10 S/CO
2023-06-16 HBsAg Nonreactive
2023-06-16 HBsAg (Value) 0.27 S/CO
2021-06-10 HBsAg (NM) Negative
2021-06-10 HBsAg Value (NM) 0.359
2021-06-10 Anti-HCV (NM) Negative
2021-06-10 Anti-HCV Value (NM) 0.00292
[exam findings]
[MedRec]
[surgical operation]
There’s no available data from PharmaCloud, possibly due to the patient not providing consent for access.
Based on the records from our hospital, the patient has visited the departments of Colorectal Surgery, General and Digestive Surgery, and Hematology-Oncology in the past three months. No prescriptions were issued by the first two departments, hence, no medication reconciliation issues were found.
Several data points have indicated that the patient’s fasting plasma glucose levels are exceeding 200mg/dL, even while being under medication with Januvia (sitagliptin 100mg) 0.5# BID and Uformin (metformin 500mg) 1# BID. There are no HbA1c readings available in the HIS5 data. It is recommended to obtain an HbA1c reading to get an understanding of the average blood glucose levels over the past two to three months.
Additionally, the patient has also been prescribed Zulitor (pitavastatin 4mg) 0.5# QD, an HMG-CoA reductase inhibitor used to lower lipid levels and reduce the risk of cardiovascular disease. However, there are no diagnoses, medical problems, or lab data related to dyslipidemia. The status of the patient’s dyslipidemia might need to be checked and clarified.
In continuation of the previous pharmacist note.
[MedRec]
[chemotherapy]
[exam findings]
[consultation] (not completed)
[immunochemotherapy] (not completed with small molecular targeted therapeutics)
This year, there have only been 2 episodes of leukopenia with a WBC count less than 3K/uL, occurring on 2023-01-14 and 2023-04-06. The injectable Cyramza (ramucirumab) has been used since 2022-03-22. Oral TKI treatment was divided at 2023-03-15: before this date, the patient was taking Giotrif (afatinib), and after this date, the patient was taking Tagrisso (osimertinib). The relationship between the usage of these drugs and the WBC level is shown in the table below, with asterisks indicating the dates when the WBC count was less than 3K/uL.
The administration time of ramucirumab does not appear to directly correlate with the episodes of leukopenia. However, all three drugs mentioned above have been reported to be associated with leukopenia. For ramucirumab, neutropenia has been reported in 5% to 24% of patients, with grade >=3: 8%. Afatinib has been associated with lymphocytopenia in 38% of patients, with grades 3/4: 9%, and decreased white blood cell count in 12% of patients, with grades 3/4: 1%. Osimertinib has been reported to cause leukopenia in 54% of patients, neutropenia in 26% to 41% of patients, with grades 3/4: <= 3%. (ref: UpToDate)
In conclusion, it is difficult to determine whether leukopenia is caused by a specific drug or a combined effect of all drugs.
As per the reimbursement guidelines of Taiwan’s NHI, the administration of G-CSF is approved for patients with non-hematological malignancies who demonstrate a WBC count of less than 1000/uL or an ANC of less than 500/uL following chemotherapy. In this particular patient’s case, the specific criteria are not fulfilled, which means that the use of G-CSF is not covered by the NHI, if G-CSF is desirable.
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings] (not completed)
[MedRec]
[surgical operation]
[chemotherapy]
[optional addition of antiemetics]
Upon reviewing the PharmaCloud database, no issues with medication reconciliation were found.
According to the records from the neurosurgery OPD, this patient has a long history of alcohol use. The patient also has a history of epilepsy, which is currently managed with Depakine (valproate). This medication is not typically recommended for use in patients with hepatic disease because its clearance is reduced in liver impairment. Therefore, it might be prudent to order comprehensive LFTs for further assessment.
[past history] - 2023-03-23 admission note
[allergy]
[family history]
[exam findings]
[MedRec]
[MultiTeam]
[surgical operation]
[chemoimmunotherapy]
[lab data]
[exam findings]
2023-06-08 MRI - L-spine
2023-05-20 MRI - brain
2023-05-19 CXR
2023-05-19 ECG
2023-04-24 Patho - colon biopsy
2023-04-21 Patho - soft tissue nontumor/mass/lipoma/debridement (Y2)
2023-04-21 CT - abdomen
2023-04-21 Bone densitometry - spine + hip
2023-04-17 CT - chest
2023-03-14 Whole body PET scan
2023-02-08 Tc-99m MDP
2023-01-17 MRI - upper abdomen
2023-01-07 CT - chest
2022-11-09, -09-07 CXR
2022-07-08 CT - chest
2022-05-18 Pure Tone Audiometry, PTA
2022-05-11 Pure Tone Audiometry, PTA
2022-04-27, 2022-04-20 CXR
2022-03-28, 2021-12-22 Tc-99m MDP whole body bone scan
2021-12-20 KUB
2021-12-09 CT - lung/mediastinum/pleura
2021-10-25 Patho - soft tissue biopsy, simple excision, non lipoma
2021-10-21 CT - whhole abdomen, pelvis
2021-09-08 CT - lung/mediastinum/pleura
2021-09-08 CT - liver, spleen, biliary duct, pancreas
2021-07-16 Patho - liver biopsy
2021-07-07 Tc-99m MDP whole body bone scan
2020-12-17 ROS1 FISH not detected
2020-12-11 EGFR, ALK IHC, PD-L1(22C3) S2020-18026 (bronchus biopsy)
2020-11-25 Patho - bronchus biopsy
2020-11-13 CT - lung/mediastinum/pleura
2020-08-12 CT - lung/mediastinum/pleura
2020-06-30 Patho - Ureter resection
2020-06-29 Patho
2020-06-13 CT - whole abdomen, pelvis
2020-03-30 CT - lung/mediastinum/pleura
2019-12-30 CT - lung/pleura
2019-09-18 CT - lung/pleura
2019-06-12 CT - lung/pleura
2019-04-11 MRI - L-spine
2019-03-15 MRI - brain
2019-03-14 Surgical pathology Level IV
2019-03-12 CT - lung/pleura
2019-03-02 CT - brain
2018-06-06 Surgical pathology Level IV
2018-05-31 Low-dose CT - lung cancer screening
[MedRec] (not completed)
[consultation]
[surgical operation]
[chemotherapy]
NCCN Non-Small Cell Lung Cancer Evidence Block 20220316 p89 — targeted therapy or immunotherapy for advanced or metastatic NSCLC
-EGFR S768I, L861Q, and/or G719X - First-line therapy -Afatinib -Erlotinib -Dacomitinib -Gefitinib -Osimertinib - Subsequent therapy -Osimertinib9
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
t:5, Lt:4+ , Lower limbs->
Rt:5, Lt:4[chemotherapy]
[exam findings]
[surgical operation]
[immunochemotherapy]
2023-06-12 - trastuzumab 600mg SC 5min (Herceptin)
2023-05-17 - cyclophosphamide 300mg/m2 457mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(lipo) Endoxan 50%)
betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL2023-04-25 - cyclophosphamide 600mg/m2 970mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 57mg D5W 250mL 2hr (AC(lipo))
2023-03-28 - cyclophosphamide 600mg/m2 996mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))
2023-02-13 - cyclophosphamide 600mg/m2 992mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))
betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg POOn 2023-01-02, breast mastectomy with regional lymph node pathology revealed the disease to be pT1cN1a; if cM0, stage IIA. Adjuvant chemotherapy with trastuzumab is indicated for this disease.
The dose-dense AC regimen (cyclophosphamide 600mg/m2, original doxorubicin 60mg/m2 replaced by liposomal doxorubicin 35mg/m2) was administered on 2023-02-13, 2023-03-28, 2023-04-25, 2023-05-17, with cyclophosphamide at 50% of the planned dose on the last administration.
The timeline of the patient’s WBC level is organized in the following table, with asterisks indicating instances where the WBC count was less than 2K/uL. The lowest WBC values occurred 2 to 4 weeks after administration of the adjusted AC regimen, suggesting a prolonged nadir or slow recovery of the white blood cells given the dosage and frequency at that time, even G-CSF was administered.
According to Taiwan’s NHI reimbursement rules, the use of G-CSF is permitted for patients with non-hematological malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL post-chemotherapy. In this patient’s case, the criteria are not met, so G-CSF is not covered by the NHI.
Granocyte (lenograstim) was administered concurrently with the adjusted AC regimen on 2023-03-28, 2023-04-25, and 2023-05-17. It’s recommended for primary and secondary prophylaxis that G-CSF administration typically starts 24 to 72 hours after the end of chemotherapy treatment (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation). ref(1): Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors. Pediatr Hematol Oncol. 2020;37(8):665-675. ref(2): Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Exp Hematol. 2008;36(1):9-16.
[diagnosis]
[exam findings]
[radiotherapy]
[chemotherapy]
2023-07-03 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)
2023-06-13
2023-05-23
2023-04-28
2023-04-06
2023-03-24
2023-03-14
2023-03-23
2023-02-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)
2023-01-13 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)
The medications Janumet (sitagliptin, metformin), Kentamin (B1, B6, B12), Diovan (valsartan), and Livalo (pitavastatin) were prescribed at Tri-Service General Hospital on 2023-06-10 and recently refilled on 2023-06-30. However, none of these drugs are currently included in the active medication list. Please verify whether these medications are still required for the patient’s current condition.
[lab data]
2023-05-10 Blood gas (Vein) 2023-05-10 PH 7.499
2023-05-10 PCO2 39.6 mmHg
2023-05-10 PO2 82.5 mmHg
2023-05-10 HCO3 30.1 mmol/L
2023-05-10 ctCO2 31.3 mmol/L
2023-05-10 Base Excess 7.1 mmol/L
2023-05-10 BEecf 6.9 mmol/L
2023-05-10 SBC 29.7 mmol/L
2023-05-10 O2 Saturation 97.2 ％
2023-05-10 Blood Osmolality 291 mOsm/Kg
2023-05-08 Blood gas (Vein) 2023-05-08 PH 7.488
2023-05-08 PCO2 47.6 mmHg
2023-05-08 PO2 47.9 mmHg
2023-05-08 HCO3 35.3 mmol/L
2023-05-08 ctCO2 36.7 mmol/L
2023-05-08 Base Excess 10.6 mmol/L
2023-05-08 BEecf 11.9 mmol/L
2023-05-08 SBC 33.0 mmol/L
2023-05-08 O2 Saturation 87.9 ％
2023-05-08 Free Light Chain κ/λ (blood) ratio 2023-05-08 FKLC 8.6
mg/L
2023-05-08 FLLC 10900.0 mg/L
2023-05-08 FK/FL ratio <0.01 ratio
2023-05-02 Protein EP 2023-05-02 Protein, total 6.1 g/dL
2023-05-02 Albumin 59.6 %
2023-05-02 Alpha-1 3.2 %
2023-05-02 Alpha-2 16.6 %
2023-05-02 Beta 11.1 %
2023-05-02 Gamma 9.5 %
2023-05-02 M-peak Negative
2023-05-02 A/G Ratio 1.50
2023-04-29 B2-Microglobulin 13021 ng/mL
2023-04-28 IgG (blood) 687 mg/dL
2023-04-27 Ca (Calcium) 2.89 mmol/L
2023-04-27 LDH 706 U/L
2023-03-17 CD45+Total leukocyte 149733 /uL
2023-03-17 %CD34+ 0.56 %
2023-03-17 CD34+ Count 846 /uL
2023-03-17 HPC Ratio 0.15 %
2023-03-17 HPC# 0.029 10^3/ul
2023-03-16 CD45+Total leukocyte 127292 /uL
2023-03-16 %CD34+ 0.67 %
2023-03-16 CD34+ Count 848 /uL
2023-03-16 HPC Ratio 0.25 %
2023-03-16 HPC# 0.036 10^3/ul
2023-03-15 CD45+Total leukocyte 117620 /uL
2023-03-15 %CD34+ 0.78 %
2023-03-15 CD34+ Count 915 /uL
2023-03-15 HPC Ratio 0.47 %
2023-03-15 HPC# 0.038 10^3/ul
2023-03-15 Ca (Calcium) 2.21 mmol/L
2023-03-15 Alkaline phosphatase 74 U/L
2023-03-15 LDH 235 U/L
2023-03-10 Ca (Calcium) 2.18 mmol/L
2023-03-10 Alkaline phosphatase 69 U/L
2023-03-10 LDH 183 U/L
2023-03-05 Alkaline phosphatase 74 U/L
2023-03-05 LDH 197 U/L
2023-03-05 Total protein 6.3 g/dL
2023-03-05 PT 10.4 sec
2023-03-05 INR 1.01
2023-03-05 APTT 26.7 sec
2023-02-20 Free Light Chain κ/λ (blood) ratio
2023-02-20 FKLC 13.3 mg/L
2023-02-20 FLLC 101 mg/L
2023-02-20 FK/FL ratio 0.13 ratio
2023-02-17 Protein EP 2023-02-17 Protein, total 5.4 g/dL
2023-02-17 Albumin 58.3 %
2023-02-17 Alpha-1 3.1 %
2023-02-17 Alpha-2 11.8 %
2023-02-17 Beta 13.1 %
2023-02-17 Gamma 13.7 %
2023-02-17 M-peak Negative
2023-02-17 A/G Ratio 1.40
2023-02-16 B2-Microglobulin 2245 ng/mL
2023-02-15 IgG (blood) 588 mg/dL
2023-02-15 HBsAg Nonreactive
2023-02-15 HBsAg (Value) 0.29 S/CO
2023-02-15 Anti-HBc Nonreactive
2023-02-15 Anti-HBc-Value 0.09 S/CO
2023-02-15 Anti-HCV Nonreactive
2023-02-15 Anti-HCV Value 0.06 S/CO
2023-02-15 Total protein 5.7 g/dL
2023-02-15 Ca (Calcium) 2.22 mmol/L
2023-02-15 LDH 206 U/L
[exam findings]
[consultation]
[MedRec]
[chemotherapy]
Bortezomib (Velcade), lenalidomide (Revlimid), and “low dose” dexamethasone (VRd) for multiple myeloma 2023-05-10 https://www.uptodate.com/contents/image?imageKey=ONC%2F91054&topicKey=HEME%2F6647
Cycle length: 21 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
DVd (Daratumumab + Velcade (bortezomib) + dexamethasone) is a Chemotherapy Regimen for Multiple Myeloma (MM) 2023-05-10 https://www.chemoexperts.com/dvd-daratumumab-velcade-bortezomib-dexamethasone.html
NHS - Chemotherapy Protocol - Myeloma - DVd (Weekly) Bortezomib-Daratumumab-Dexamethasone (cycles 1 to 8) https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Myeloma/DVd-Weekly-Daratumumab-Bortezomib-Dexamethasone-Cycles-1-to-8.pdf
The DVd regimen (Daratumumab + Velcade (bortezomib) + dexamethasone) was initiated on 2023-05-12. Pancytopenia was observed, but it’s important to note that bicytopenia (anemia and thrombocytopenia) was already present even before the regimen started. Furthermore, the fluctuations in HGB and PLT levels are smaller than those in the WBC count. This can be attributed to the fact that the patient has received multiple blood transfusions at our hospital (on 2023-03-16, 2023-04-28, 2023-05-09, 2023-05-15, 2023-05-19, 2023-05-26, 2023-05-31, 2023-06-08, 2023-06-13), which have helped replenish red blood cells and platelets.
2023-06-13 PLT 45 x10^3/uL
2023-06-11 PLT 10 x10^3/uL
2023-06-08 PLT 51 x10^3/uL
2023-06-05 PLT 24 x10^3/uL
2023-06-02 PLT 34 x10^3/uL
2023-05-31 PLT 14 x10^3/uL
2023-05-29 PLT 54 x10^3/uL
2023-05-28 PLT 89 x10^3/uL
2023-05-26 PLT 8 x10^3/uL
2023-05-24 PLT 33 x10^3/uL
2023-05-23 PLT 57 x10^3/uL
2023-05-22 PLT 19 x10^3/uL
2023-05-19 PLT 78 x10^3/uL
2023-05-17 PLT 25 x10^3/uL
2023-05-15 PLT 58 x10^3/uL
2023-05-12 PLT 15 x10^3/uL
2023-05-10 PLT 49 x10^3/uL
2023-05-08 PLT 23 x10^3/uL
2023-06-13 HGB 7.7 g/dL
2023-06-11 HGB 7.5 g/dL
2023-06-08 HGB 6.7 g/dL
2023-06-05 HGB 7.4 g/dL
2023-06-02 HGB 8.7 g/dL
2023-05-31 HGB 7.5 g/dL
2023-05-29 HGB 8.5 g/dL
2023-05-28 HGB 8.1 g/dL
2023-05-26 HGB 8.9 g/dL
2023-05-24 HGB 9.4 g/dL
2023-05-23 HGB 8.5 g/dL
2023-05-22 HGB 7.6 g/dL
2023-05-19 HGB 8.4 g/dL
2023-05-17 HGB 9.0 g/dL
2023-05-15 HGB 6.8 g/dL
2023-05-12 HGB 8.8 g/dL
2023-05-10 HGB 8.2 g/dL
2023-05-08 HGB 8.0 g/dL
Since the VRd (bortezomib, lenalidomide, dexamethasone) regimen has already been utilized from 2022-08-17 to 2022-12-29, and the DVd regimen is preferred in patients who are refractory to full doses of lenalidomide or a lenalidomide-containing triplet, the choice of DVd regimen is reasonable in this case. The major toxicities of the DVd regimen include peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, and nausea. At present, the WBC count has exceeded the upper limit of normal, reversing the previous leukopenia and presenting as a problem of leukocytosis.
[DVd regimen renal dosing checked]
The recent lab data indicates that the patient’s renal function has stopped deteriorating and shows signs of slight recovery.
For patients with CrCl between 15 to 89 mL/minute, there are no dosage adjustments provided in the daratumumab manufacturer’s labeling. Studies show that this range of renal function does not significantly affect the pharmacokinetics of daratumumab. Additionally, no dosage adjustment is necessary for bortezomib in patients with renal insufficiency. For the current treatment regimen of multiple myeloma, there is no need for dosage adjustment.
[tube feeding]
[diagnosis] - 2023-04-01 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
Xgeva (denosumab 120mg) CXGEV01
[exam findings]
The two medications, Plaquenil (hydroxychloroquine) and dipyridamole, which were prescribed by our Rheumatology and Immunology OPD on 2023-05-15, are correctly listed on the active medication list. No issues with medication reconciliation were identified.
Given that hematemesis was just added to the patient’s medical problem list on 2023-06-08, the inclusion of tranexamic acid could be beneficial in reducing gastrointestinal bleeding.
[IVIG usage]
According to UpToDate, immune globulin can be used for acute disseminated encephalomyelitis, IV: 400 mg/kg once daily for 5 days.
Based on the patient’s body weight of 80kg and Privigen at 5gm per vial, a dosage schedule of 7-7-6-6-6 vials over 5 days appears to fulfill the recommended dosage.
While the package insert doesn’t specify a need for dilution, if dilution is preferred, D5W can be used as the solvent.
Infusions should ideally begin at a rate of 0.5 to 1 mL/kg/hour for the first 15 to 30 minutes. If no adverse reactions occur, the rate can be incrementally increased every 15 to 30 minutes to a maximum of 3 to 6 mL/kg/hour. This information is referenced from https://www.ncbi.nlm.nih.gov/books/NBK554446/. An alternative infusion rate reference can be found at https://www.gov.nl.ca/hcs/files/bloodservices-resources-pdf-adult-invig-inf-table.pdf.
[diagnosis] - 2023-03-27 admission note
[past history]
[allergy]
[family history]
[lab data]
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
[tube feeding]
According to the package insert of Valcyte (valganciclovir), once ingested, it rapidly converts to ganciclovir, which has been shown in animal studies to be mutagenic, teratogenic, and carcinogenic. This morning I called the drug supplier (YuLi Co., Ltd.), who advised against direct contact with the drug substance on the mucous membranes to avoid exposure, so they don’t recommend crushing or splitting the pill by hand. However, they suggested that the pill could be broken into smaller pieces without the operator’s hands directly touching it, dissolved in an appropriate amount of drinking water, and then administered with food via tube feeding.
Lab data from early Feb 2023 showed a short trough. However, recent results indicate that the SCC antigen has doubled compared to late Dec 2022.
The patient is currently being treated with Valcyte (valganciclovir), Morcasin (sulfamethoxazole/trimethoprim), and Mycostatin (nystatin) for suspected respiratory infections.
During this hospital stay, no issues with medication reconciliation were identified, and the drugs recently prescribed and listed in the NHI PharmaCloud System were properly prescribed as self-carried items to address the patient’s underlying conditions.
There is no specific pharmacist shift handover to follow in this patient.
[Zavicefta 2g/0.5g powder for concentrate for solution for infusion - Usage and Precautions ] for the patient’s primary nurse
[exam findings]
[consultation]
{gastric cancer with peritoneal seeding, pT4aN2M1, stage IV, (poorly cohesive carcinoma, signet-ring cell type) s/p total gastrectomy with D2 LN dissection & CCRT}
[compatibility]
There is no compatibility information available in Micromedex for concurrent administration of Nako No.5 and Oliclinomel N4-550E.
Nako No.5 injection contains: - sodium chloride - sodium acetate anhydrous - potassium acetate - magnesium chloride 6H2O - potassium phosphate monobasic - dextrose monohydrate
Oliclinomel N4-550E Emulsion for Infusion contains: - sodium acetate 3H2O - sodium glycerophosphate 5H20 - potassium chloride - magnesium chloride 6H2O - glucose monohydrate - calcium chloride 2H2O
The electrolyte components in both Nako No.5 and Oliclinomel N4-550E share a high degree of similarity, which suggests that they are unlikely to be incompatible when administered concurrently through a Y-line immediately prior to administration.
{SCC of esophagus, lower third, with mediastinal & SCF LAPs and multiple brain metastases, stage IV}
[diagnosis] - 20230110 admisstion note
[past history]
[family history]
[exam findings]
Port-A catheter inserted into SVC via left subclavian vein.
approriately positioned endotracheal tube in place
s/p VATS esophagectomy and gastric tube reconstruction with gastric tube inserted
Right internal jugular central venous catheter with tip in the SVC
s/p right chest tube in place, its tip directed superomedially, projecting over Rt upper hemithorax
s/p left chest tube in place, its tip directed superomedially, projecting over 6th rib
extensive increased opacity over Rt lung field
Lung volume reduction and increased opacity over RLL
Subcutaneous emphysema in the right neck and chest wall
2022-07-15 Patho - esophagus subtotal/total resection
2022-07-01 Pulmonary Flow Volume Loop
2022-06-27 CXR
2022-06-01 Patho - bronchus biopsy
2022-05-19 CT - chest
2022-03-10 Patho - esophageal biopsy
2022-03-01 Esophagography
2022-01-17 MRI - brain
2022-01-14 CT - lung/mediastinum/pleura
2021-10-11 CT - lung/mediastinum/pleura
2021-10-08 CT - brain
2021-04-28 Whole body PET scan
2021-04-28 CT - lung/mediastinum/pleura
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2
2022-12-21 - nivolumab 3mg/kg 200mg 30min D1 + oxaliplatin 85mg/m2 145mg 2hr D2 + leucovorin 400mg/m2 700mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)
2022-12-01 - nivolumab 3mg/kg 180mg 30min D1 + oxaliplatin 85mg/m2 148mg 2hr D2 + leucovorin 400mg/m2 680mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)
2022-04-22 - cisplatin 40mg/m2 77mg 4hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 2800mg/m2 5430mg 46hr
2022-03-29 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2022-03-14 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2022-02-15 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2022-01-24 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2022-01-11 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2021-12-22 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2021-12-07 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2021-11-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-11-02 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-10-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)
2021-09-29 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)
2021-08-24 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-08-10 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-07-27 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-07-14 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
[exam findings]
[MedRec]
[chemotherapy]
Nanoparticle albumin bound paclitaxel (nab-paclitaxel) 2023-05-24 https://www.uptodate.com/contents/nanoparticle-albumin-bound-paclitaxel-nabpaclitaxel-drug-information
[exam findings]
[MedRec]
[consultation]
This patient visited a local clinic on 2023-05-11 for his primary hypertension (PharmaCloud only reveals one main diagnosis, there should be also diabetes diagnosed) and be prescribed with amlodipine, losartan and glimepiride. Currently Norvasc (amlodipine), Amepiride (glimepiride) and 與 losartan 同藥理作用的 Olmetec (olmesartan) are shown in the active medication list, no reconciliation issue identified.
2023-05-19 anaerobic culture for deep neck wound/pus showed peptostreptoccus spp. 3+
[exam findings]
Laterality: right [MedRec]
[consultation]
[chemotherapy]
Based on the PharmaCloud database, this patient has only sought medical care at our hospital in the past three months. On 2023-05-27, our metabolic physician recently prescribed refillable medications including Uformin (metformin), Trajenta (linagliptin), Lipanthyl (fenofibrate), and Zulitor (pitavastatin). These drugs have been correctly integrated into the current active medication list without any issues in medication reconciliation.
[exam findings]
[surgical operation]
[chemotherapy]
2023-05-16 - paclitaxel 135mg/m2 260mg NS 300mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr + [paclitaxel 40mg/m2 77mg + cisplatin 30mg/m2 58mg + gentamicin 40mg + sodium bicarbonate 2800mg NS 800mL] IP 1hr
2023-04-23 - [Liposome doxorubicin 30mg/m2 60mg D5W 250mL 90min + carboplatin AUC 5 700mg NS 250mL] IP (HIPEC)
2023-03-28 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr
2023-03-07 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr
2023-02-09 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr
2023-01-20 - paclitaxel 175mg/m2 360mg NS 300mL 1hr + carboplatin AUC 5 740mg NS 250mL 2hr
[exam findings]
[chemotherapy]
[note]
Systemic Therapy for Endometrial Carcinoma - Endometrial Carcinoma - NCCN Clinical Practice Guidelines in Oncology - NCCN Evidence Blocks - Version 2.2023 - April 28, 2023 - ENDO-D
Primary or Adjuvant Therapy (Stage I-IV)
Recurrent Disease
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemoimmunotherapy]
2023-05-25 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
2023-04-21 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
2023-03-09 - [oxaliplatin 300mg/m2 530mg D5W 3000mL + sodium bicarbonate 4200mg + gentamicin] IP 30min
2022-07-25 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr
2022-07-05 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr
2022-06-21 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr
2022-06-08 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4770mg NS 500mL 46hr
2022-05-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4750mg NS 500mL 46hr
2022-04-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr
2022-03-28 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr
2022-03-14 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr
2022-02-24 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
2022-02-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
2022-01-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
2022-01-03 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
[diagnosis] - 2022-12-15 admission note
[exam findings]
[body fluid]
[MedRec]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[note]
PREVIOUSLY UNTREATED PATIENTS - Trastuzumab plus pertuzumab plus a taxane - 2022-11-24 UpToDate - https://www.uptodate.com/contents/systemic-treatment-for-her2-positive-metastatic-breast-cancer
[tube feeding]
A grinding substitution method for Tykerb (lapatinib 250mg) tab
After over 15 kg of weight loss between late August and early December in 2022, the patient’s weight has remained at approximately 41kg for one month, with no further noticeable decline in her weight.
The elevated D-dimer readings are getting closer to the normal limits in a gradual manner. Given that the half-life of the D-dimer is only 15.8 (13.1 - 23.1) hours (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693750/), could this slow decline be indicative of latent fibrin degradation?
It is advised to assess LVEF immediately prior to pertuzumab/trastuzumab initiation, every 3 months during pertuzumab/trastuzumab therapy, every 3 weeks if pertuzumab/trastuzumab is withheld for significant left ventricular cardiac dysfunction, and every 6 months for at least 2 years following completion of adjuvant pertuzumab/trastuzumab therapy. Pre-pertuzumab/trastuzumab 2D transthoracic echocardiography was performed on 2022-08-11, so it might be in need of updating. (Nov and Dec 2022 CXR showed borderline cardiomegaly and enlargement of cardiac silhouette.)
Since bilirubin total was 0.95 mg/dL on 2023-01-11, there is no need to adjust the dose of paclitaxel.
Over 15 kg of body weight have been lost in the past four months (41.2kg 2022-12-15 <- 55.8kg 2022-08-24). It is possible that the serum creatinine level remains below LLN since August 2022 as a result of insufficient dietary intake or muscle mass loss (malnutrition, muscle wasting). It should be necessary to encourage the patient to consume more food and there may be benefits to prescirbe megestrol as an appetite stimulant.
The presence of elevated plasma D-dimer concentrations indicates recent or ongoing intravascular coagulation and fibrinolysis. Although the reading remained high, it trended downward, a relatively positive sign. The metastatic liver lesion reduced clearance of fibrin degradation products?
According to the patient’s updated liver function lab results, paclitaxel dosage does not need to be adjusted.
[chemoimmunotherapy]
Trastuzumab and Pertuzumab, both monoclonal antibodies utilized in the management of HER2-positive breast cancer, can lead to several dermatologic side effects.
With Trastuzumab, patients may experience a skin rash in approximately 4% to 18% of cases.
Our dermatologist has prescribed Mycomb (nystatin, neomycin, gramicidin, triamcinolone) TOPI and Exelderm (sulconazole nitrate) EXT for the symptom on 2023-05-15.
In case of Grade 3 or higher paronychia - which is inflammation of the skin around the nails - the following approach is generally recommended aiming to manage the paronychia effectively while minimizing the impact on the patient’s overall cancer treatment plan. (ref: Prevention and management of dermatological toxicities related to anticancer agents: ESMO Clinical Practice Guidelines. Ann Oncol. 2021;32(2):157-170)
[diagnosis] - 2022-11-01 discharge note
[past history]
Type 2 diabetes mellitus, hyperlipidemia, and hypertension for 8 years under medications treatment and follow up at endocrinology & metabolism clinic.
History of operation:
[Current Medication] - 20230220 admission note
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Based on the PharmaCloud database, it appears that the patient has only been seen at our hospital for the past three months. No discrepancies or issues were identified in the medication reconciliation process for the patient upon admission this time.
The CT scan performed on 2023-01-20 showed no evidence of tumor recurrence. In addition, on 2023-05-03, both tumor markers, CEA and CA199, fell into the normal range for the first time. This is an encouraging development in the patient’s condition to date.
The patient experienced a severe eruption of pruritic papules and plaques over the trunk in early May 2023, probably in response to medication. The dermatologist has prescribed appropriate medications to treat this skin reaction. Please monitor closely for any recurrence of these symptoms.
The patient’s serum glucose levels have remained high, exceeding 270 mg/dL for the past two days. All medications prescribed by our endocrinologist have been added to the active formulary, and the patient is unwilling to take insulin injections. This makes appropriate dietary control even more important. It may be beneficial to schedule a consultation with a dietitian during the patient’s hospitalization to provide guidance on dietary changes to manage blood glucose levels.
All-RAS + BRAF + IHC results were like 700811991’s.
[consultation]
[chemotherapy]
[diagnosis] - 2023-04-09 admission note
[exam findings]
[MedRec]
[chemothereapy]
Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma 2023-05-22 https://www.uptodate.com/contents/image?imageKey=ONC%2F101205&topicKey=HEME%2F6647
[lab data]
prior to peripheral blood stem cell harvest
2023-04-17 CMV viral load assay Target not detecetedIU/mL
2023-04-17 EBV DNA quantitative amplification test <120
copies/mL
2023-04-13 EB VCA IgG Positive Ratio
2023-04-13 EB VCA IgG Value 5.3 Ratio
2023-04-12 EB VCA IgM Negative Index
2023-04-12 EB VCA IgM Value 0.0 Index
2023-04-10 RPR/VDRL Nonreactive
2023-04-10 CMV IgM Nonreactive
2023-04-10 CMV IgM Value 0.54 Index
2023-04-10 CMV_IgG Reactive
2023-04-10 CMV_IgG Value 834.1 AU/mL
2023-04-10 HIV Ab-EIA Nonreactive
2023-04-10 Anti-HIV Value 0.05 S/CO
2023-04-10 Anti-HBc Nonreactive
2023-04-10 Anti-HBc-Value 0.24 S/CO
2023-04-10 Anti-HCV Nonreactive
2023-04-10 Anti-HCV Value 0.06 S/CO
2023-04-10 HBsAg Nonreactive
2023-04-10 HBsAg (Value) 0.50 S/CO
2023-04-10 Anti HTLV I/II Nonreactive
2023-04-10 Anti HTLV I/II Value 0.05 S/CO
[lab data]
[exam findings]
[MedRec]
[consultation]
[assessment]
Dacogen (decitabine)
[past history]
Heart:(-)
Chest:(-)
Liver:(-)
Kidney:(-)
H/T:(-)
DM:(-)
Other medical:denied
Surgical: s/p Peripheral glioma excision 20+ years ago
Menstrual history: G4P2SA2, NSD x2
Menarche at the age of 13 years old
Menopaused at the age of 56 years old
Menstrual cycle:Duration/Interval:4days/28days
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemotherapy]
2023-05-16 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-04-25 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-03-21 - liposome doxorubicin 35mg/m2 60mg D5W 250mL IP 90min + carboplatin AUC 5 600mg NS 250mL IP 90min (for HIPEC in operation)
2023-02-23 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr
2023-01-31 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr
2023-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1100mg NS 250mL 2hr
[assessment]
[exam findings]
[consultation]
[MedRec]
[chemotherapy]
[note]
Bortezomib (Velcade) plus cyclophosphamide and dexamethasone (VCD or CyBorD) for multiple myeloma 2023-04-24 https://www.uptodate.com/contents/image?topicKey=ONC%2F85687§ionRank=1&imageKey=ONC%2F50061
Cycle length: 28 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
Treatment of Clostridioides difficile infection (CDI) in adults 2023-05-17 https://www.uptodate.com/contents/image?topicKey=ID%2F2698&imageKey=ID%2F53273
On 2023-05-14, the patient’s WBC was 7.37K/uL, creatinine was 1.01mg/dL, and stool occult blood was 2+. Stool culture obtained on 2023-05-15 was negative for Clostridioides difficile toxin A/B but positive for glutamate dehydrogenase (GDH). The patient had 9 and 8 bowel movements on 2023-05-15 and 2023-05-16, respectively. Therefore, the prescription of oral vancomycin at a dose of 125 mg 4 times daily is appropriate and unproblematic.
Now that the pathogen has been identified, the previously prescribed and currently active medication, Metrozole (metronidazole) 500mg PO Q8H, could potentially be discontinued, assuming there are no hypotension or shock, ileus, megacolon and/or other ongoing infectious conditions.
According to the HIS5 database, there have been no other culture reports on Clostridioides Difficile Infection (CDI) in the past 6 months. In the event of a recurrent infection, a tapered and pulsed regimen of vancomycin could be considered. Here is a possible schedule:
[assessment]
The patient has been diagnosed with Multiple Myeloma (MM) and was started on VCd regimen on 2023-01-03. All of the patient’s medications listed in PharmaCloud were prescribed by our hospital. No medication reconciliation issues were identified.
After starting the VCd regimen, there was a decrease in the B2 microglobulin level. However, the most recent reading indicates that the level has nearly doubled from the previous low in approximately 1.5 months.
Currently, there is no evidence that the patient is developing thrombocytopenia, peripheral neuropathy or neuropathic pain.
[exam findings]
[present illness] - 2023-02-23 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surigcal operation]
[radiotherapy]
[chemotherapy]
2023-04-25 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFOX)
2023-03-27 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1-4 (CCRT)
2023-02-23 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1, 2, 5, 7 (excluding weekend and 2/28 holiday) (CCRT)
According to the PharmaCloud database, all of the patient’s recent medications have been prescribed by our hospital, and no issues with medication reconciliation have been detected.
On 2023-05-15, the patient’s WBC count was observed to be 1.89K/uL, indicating leukopenia. This was first noted in the HIS5 system 3 weeks after the last administration of FOLFOX on 2023-04-25. When this event became known, Granocyte (lenograstim) was administered for two consecutive days. The nadir may occur later than expected, or blood cell monitoring should be more frequent.
This patient experienced hand-foot syndrome following the second dose of concurrent chemotherapy with 5-FU in late March 2023. The patient is currently undergoing FOLFOX treatment. If hand-foot syndrome reoccurs, it may be advisable to omit the 5-FU bolus.
The patient has underlying kidney concerns, and the NSAID Celebrex (celecoxib) is currently prescribed as needed. If the primary purpose of using celecoxib is for pain management, considering an alternative like acetaminophen could be less harmful to the kidneys.
[assessment]
{malignant neoplasm of unspecified site of left female breast, cT4aN3M1, stage IV}
[exam findings]
[surgical operation]
[chemoimmunotherapy]
[blood WBC]
[G-CSF]
[tube feeding]
As of 2023-05-12, the patient’s serum potassium level was measured at 3.2 mmol/L. Currently, Const-K is the only oral potassium supplement available in this hospital. If intravenous potassium supplementation is not the preferred method, it’s recommended to crush the Const-K tablet into small enough particles to pass through the feeding tube, and administer the supplement with sufficient water. It’s preferable to give this medication with meals due to its original extended-release design.
[past history]
Heart:(-)
Chest:(-)
Liver:(-)
Kidney:(-)
H/T:(-)
DM:(-)
Surgical:
Menstrual history: G2P2, menopause at age of 48
[allergy]
[family history]
[lab data]
2023-01-11 Anti-HBc Nonreactive
2023-01-11 Anti-HBc-Value 0.89 S/CO
2023-01-11 Anti-HBs 329.77 mIU/mL
2023-01-11 Anti-HCV Nonreactive
2023-01-11 Anti-HCV Value 0.07 S/CO
2023-01-11 HBsAg Nonreactive
2023-01-11 HBsAg (Value) 0.31 S/CO
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[chemotherapy]
[assessment]
The PharmaCloud database reveals that the patient’s recent drugs have all been prescribed at our hospital. Currently, there are no issues detected with medication reconciliation in the active prescription.
The patient’s anemia, as evidenced by a decrease in hemoglobin level from 10.2 g/dL on 2023-05-02 to 8.1 g/dL on 2023-05-09, is currently being treated with a transfusion of 2 units of packed red blood cells (P-RBC), scheduled for 2023-05-11, as indicated.
The patient’s lab data reveals a decreasing trend in serum albumin levels, raising the possibility of a protein-losing gastroenteropathy. However, current records do not indicate the presence of edema, ascites or pleural and pericardial effusions. Furthermore, liver and kidney function appear to be within or not far from normal ranges based on the lab data, suggesting that heavy proteinuria or impaired protein synthesis due to liver disease are less likely causes. It is recommended to encourage the patient to pay more attention to nutritional supplementation to prevent malnutrition.
Intestinal leakage of plasma proteins occurs via one of the following mechanisms:
The CT scan on 2023-04-22 revealed recurrent tumors in the pelvic cavity measuring 4.7cm and 7.9cm, respectively. These tumors have invaded adjacent structures, causing right hydronephrosis and hydroureter, and lymph nodes are also evident in the retroperitoneum. These findings might be related to the observed clinical phenomena mentioned above?
[assessment]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
Please be aware that the patient’s renal function has been declining over the past three days. At present, there’s no need for a dose adjustment, but it’s crucial to continue monitoring closely.
Lab data has shown signs of recovery in the patient’s WBC count. However, the PLT count continues to hover at relatively low levels, never reaching 100K/uL.
Indications for platelet transfusion include actively bleeding patients with thrombocytopenia who should receive immediate platelet transfusion to maintain platelet counts above 50K/uL in most bleeding situations, including disseminated intravascular coagulation (DIC), and above 100K/uL in central nervous system bleeding.
Unfortunately, there are no perfect tests to predict spontaneous bleeding. Studies in patients with thrombocytopenia suggest that spontaneous bleeding can occur even with platelet counts above 50K/uL. However, bleeding is much more likely when the platelet count falls below 5K/uL. For individuals with platelet counts between 5K and 50K/uL, clinical observations may be useful in deciding whether to transfuse platelets.
[diagnosis] - 2023-03-23 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
{not completed}
[MedRec]
[chemotherapy]
[assessment]
[MedRec]
[chemotherapy]
[assessment]
[lab data]
[exam findings]
[consultation]
[MedRec]
[radiotherapy]
[chemotherapy]
[tube feeding]
Nexium (esomeprazole) should not be crushed. Instead, it should be dissolved in sufficient drinking water before tube feeding.
[tube feeding]
[tube feeding]
[diagnosis] - 2023-05-07 admission note
[present illness]
[past history] - 2023-05-07 admission note
[family history]
[lab data]
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
From 2022-11-21 to 2023-01-09, the patient was treated with Avastin plus FOLFOX for his K-RAS-mutated sigmoid colon adenocarcinoma. However, a CT scan on 2022-12-02 showed progressive disease with multiple liver and lung metastases, as well as metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space. As a result, the regimen was changed to Avastin plus FOLFIRI on 2023-01-27. Due to dizziness and headache experienced during chemotherapy on 2023-03-01, the fluorouracil dose was reduced by half starting on 2023-03-21.
After the new regimen was applied, the tumor marker CEA has remained relatively unchanged; however, the readings are approximately twice as high as they were before.
The Covid-19 fast screen was positive on 2023-04-24, but the patient has since recovered. Vital signs are currently stable. CT and CXR revealed lung mets with multiple nodular opacities in both lungs, which do not significantly impair the patient’s respiratory function yet.
The underlying conditions are currently being managed with appropriate medications: anemia is treated with Foliromin (ferrous sodium citrate), toe numbness is treated with Kentamin (B1, B6, B12), right upper quadrant abdominal and rib area pain is treated with Tramacet (tramadol, acetaminophen) and Neurontin (gabapentin), respiratory symptoms are treated with Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), oral candidiasis is treated with Mycostatin (nystatin), and intermittent diarrhea is managed with loperamide and Smecta (dioctahedral smectite) as needed (PRN).
[drug interaction]
The ability of oral iron preparations to reduce the absorption of oral quinolones is well established and has been demonstrated in numerous pharmacokinetic studies. Various oral iron preparations have been reported to reduce quinolone AUCs by the following percentages: ciprofloxacin (33% to 70%), levofloxacin (19%), lomefloxacin (14%), moxifloxacin (61%), norfloxacin (51% to 73%), ofloxacin (25%), and sparfloxacin (28%). The maximum serum concentrations of oral quinolones were reduced by the following percentages: ciprofloxacin (46% to 75%), levofloxacin (45%), lomefloxacin (28%), moxifloxacin (41%), norfloxacin (75% to 82%), ofloxacin (36%), and sparfloxacin (46%). It is recommended to administer oral quinolones at least several hours before (4 h for moxifloxacin and sparfloxacin, 2 h for others) or after (8 h for moxifloxacin, 6 h for ciprofloxacin and delafloxacin, 4 h for lomefloxacin, 3 h for gemifloxacin, 2 h for enoxacin, levofloxacin, norfloxacin, ofloxacin, pefloxacin, or nalidixic acid) oral iron preparations.
Due to the fact that Cravit (levofloxacin) and Foliromin (ferrous sodium citrate) were prescribed as QDAC and BID, respectively. To maintain Cravit’s effectiveness, Foliromin might be moved to QL and QN.
Please monitor for diminished effects of the quinolone if dose separation cannot be achieved.
[diagnosis] - 2023-04-26 admision note
[past history] - 2023-04-26 admision note
[allergy]
[family history]
[exam findings]
[lab data]
[consultation]
[MedRec]
On 2023-05-08 at 06:05, the patient’s SpO2 dropped to 69%, accompanied by an increased heart rate of 100 bpm. This indicates possible respiratory distress or compromised oxygenation, and an O2 mask is placed appropriately.
If the patient continues to experience hemoptysis, inhaled tranexamic acid could be considered as a potential treatment option to reduce bleeding. This antifibrinolytic agent has been shown to effectively control bleeding and may provide relief to the patient.
[exam findings]
[consultation]
[surgical operation]
2022-02-11 MWA, Microwave ablation
2021-09-27 VATS, decortication
2021-03-29 VATS, LUL and LLL wedges resection for metastasectomy + pneumolysis
2021-09-16 RFA, Radiofrequency Ablation
2021-08-19 RFA, Radiofrequency Ablation
2020-07-01 3D VATS RUL, RML and RLL wedge resections + LND. decortication
2018-03-29 laparoscopic lower anterior resection w/ TaTME and S3, S8 subsegmentectomy + S5 cyst unroofing (Taipei Veterans General Hospital)
[radiotherapy]
[chemoimmunotherapy]
[note]
FOLFOXIRI chemotherapy for metastatic colorectal cancer 2023-04-25 https://www.uptodate.com/contents/image?topicKey=ONC%2F2503&imageKey=ONC%2F70559
Cycle length: 14 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity (The specific dose alteration parameters for the FOLFOXIRI regimen in colorectal cancer patients were not published in the original phase III trial. The following suggestions are based upon dose reductions used in a trial using a comparable regimen (FOLFIRINOX) for advanced pancreatic cancer.)
[tube feeding]
{not completed}
[MedRec]
[exam findings]
[assessment - not posted]
[exam findings]
[MedRec]
[chemoimmunotherapy]
[assessment]
{not completed}
[MedRec]
[surgical operation]
[medication]
2023-03-15 ~ 2023-03-29 - UFT (tegafur 100mg, uracil 224mg) 2# BID
2022-02-08 ~ 2022-04-25 - TS-1 (tegafur, gimeracil, oteracil) 2# BID
2021-09-09 ~ 2021-10-15 - Xeloda (capecitabine 500mg) 2# BID
B-Red (hydroxocobalamin 1mg)
[diagnosis] - 2023-03-22 SOAP
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[chemotherapy]
[note]
hyperbilirubinemia - ref: 2023-05-05 UpToDate
CA199, CEA - ref: 2023-05-05 ChatGPT
Nab-paclitaxel and gemcitabine treatment was first initiated on 2023-03-27 and is currently ongoing. The 3rd dose was administered on 2023-04-24 with a 20% reduction in dosage due to dizziness, nausea, and vomiting. The patient also experienced conscious disturbance and abdominal fullness, which led to ascites tapping on 2023-05-02.
After receiving 3 doses of the regimen, the patient’s tumor marker CA199 remains relatively unchanged, while there is a significant increase in CEA levels.
The TPR panel indicated no bowel movement on 2023-05-03 and 2023-05-04. It is suggested to assess whether the patient has developed constipation, as bisacodyl is prescribed as needed (PRN) for this issue.
[tube feeding]
As of 2023-05-01, the patient’s serum potassium level has returned to the normal range of 3.5 mmol/L. However, the current prescription for Const-K will expire on 2023-05-04, and it may be worth considering discontinuing this medication. It should be noted that the potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred (Const-K remains the only oral potassium supplement available today), please crush the tablet into particles and administer it with water.
For patients who have difficulty swallowing Protase (pancrelipase) capsules, the capsule can be opened and the enteric-coated granules can be released into a small amount of liquid food with a pH not exceeding 5.5. Tube feed the drug particles with drinking water or juice to ensure complete ingestion.
As for Megejohn (megestrol acetate), since our hospital has Megest (megestrol 40mg/mL, 120mL/bot) in stock, it is suggested to switch Megejohn to the Megest oral suspension.
[exam findings]
[MedRec]
[radiotherapy]
[chemotherapy]
2023-05-04 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4555mg NS 250mL 46hr (FOLFIRI)
2023-04-07 (FOLFIRI)
2023-03-22 (FOLFIRI)
2023-03-08 (FOLFIRI)
2023-02-22 (FOLFIRI)
2022-02-23 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)
2022-02-09 (FOLFOX)
2022-01-26 (FOLFOX)
2022-01-12 (FOLFOX)
2021-12-29 (FOLFOX)
2021-12-15 (FOLFOX)
2021-12-01 (FOLFOX)
2021-11-17 (FOLFOX)
2021-11-03 (FOLFOX)
2021-10-20 (FOLFOX)
2021-10-01 (FOLFOX)
2021-09-09 (FOLFOX)
[assessment]
No medication reconciliation issues have been identified for this patient.
The patient appears to be tolerating the current regimen well, and his labs are mostly within normal ranges, with the exception of slightly elevated liver function tests and BUN.
[allergy]
[family history]
[exam findings]
[consultation]
[MedRec]
[exam findings]
[assessment]
Hyperleukocytosis (leukostasis) was confirmed by laboratory tests, and the patient has been treated with Hydrea (hydroxyurea 500mg) 2# TID since 2023-05-03, which has helped to control the high WBC count.
Leukostasis can be diagnosed when a biopsy of affected tissue shows white cell clots in the microvasculature (2023-05-02 CT: suspected splenic infarct). Please be aware of possible clinical signs of leukostasis, such as
Feburic (febuxostat) is used as prophylaxis for potential tumor lysis syndrome. Lab data show that elevated serum uric acid levels have returned to normal following administration of the drug.
Caution should be exercised when using intravenous contrast at a time when renal function may be compromised by leukostasis or tumor lysis syndrome and dehydration. (2023-05-04 BUN 29mg/dL, Cre 1.10mg/dL, eGFR 70.75, normal values in K. The patient is currently hydrated with NS 500mL BID. No apparent renal insufficiency at this time).
[lab data]
[exam findings]
[MedRec]
[note]
FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-04 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571
[chemotherapy]
[assessment]
This is the first time the patient has received FOLFIRINOX chemotherapy for his pancreatic cancer, with a reduced dose of irinotecan (180mg/m2 reduced to 120mg/m2) and oxaliplatin (85mg/m2 reduced to 65mg/m2). Thus far, no significant adverse reactions have been observed.
2023-05-03 Anti-HBc Reactive
2023-05-03 Anti-HBc-Value 8.55 S/CO
[diagnosis] - 2023-05-02 admission note
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[chemoimmunotherapy]
[assessment]
The patient was diagnosed with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05, followed by FOLFOX treatment starting on 2022-10-05.
A CT scan on 2022-11-28 showed liver metastases in progression, and a PET scan on 2022-12-26 revealed that the gastric cancer had progressed, with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB. After receiving six doses of FOLFOX (with the last dose administered on 2022-12-23), the patient’s regimen was changed to FOLFIRI starting on 2023-01-12.
The patient was admitted to the hospital for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, making this the 2nd dose). The patient tolerates the regimen well, and no significant adverse reactions have been observed.
After partial or total gastrectomy, the availability of gastric acid and intrinsic factor, both essential for vitamin B12 absorption, is reduced or eliminated. As a result, individuals who have undergone partial or total gastrectomy would benefit from supplementing their diet with oral vitamin B12 or receiving intramuscular or subcutaneous injections of vitamin B12. B-Red (hydroxocobalamin) is appropriately administered as a daily supplement for this patient.
The patient’s underlying condition of chronic viral hepatitis B is appropriately treated with Baraclude (entecavir).
A review of the PharmaCloud database reveals that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.
The patient was proved with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05 then FOLFOX was applied since 2022-10-05.
2022-11-28 CT showed liver mets in progression and 2022-12-26 PET showed the gastric cancer progressed with suspected regional lymph nodes and liver mets, cTxN2M1, stage IVB. After administration of 6 times of FOLFOX (last dose on 2022-12-23), then the regimen changed to FOLFIRI since 2023-01-12.
The patient admitted this hospitalization for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, this time the 2nd dose). The patient tolerates the regimen well and no obvious adverse reaction is found.
The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.
[diagnosis]
[past history]
[family history]
[exam findings]
[chemotherapy]
On 2022-10-07, 2023-01-05, and 2023-04-29, CT scans demonstrated disease progression, with the most recent scan also revealing possible liver metastases. This information highlights the need for close monitoring and potentially re-evaluating the patient’s treatment plan.
The patient’s renal function improved according to the most recent lab values.
If the initial consideration for reducing the dose of topotecan was due to the patient’s inadequate renal function, this reason becomes less important. However, the patient also experienced leukopenia and thrombocytopenia after the standard dose of 1.5 mg/m2 topotecan in January 2023. The full standard dose may potentially lead to episodes of leukopenia and/or thrombocytopenia. A moderate titration to 0.9 or 1.0 mg/m2 from 0.75mg/m2 could be considered as a feasible option to balance treatment efficacy and side effect profile if the same regimen is intended to be continued.
This patient has a tendency to develop leukopenia and/or thrombocytopenia after receiving the normal dose of 1.5mg/m2 topotecan. However, after the dose was reduced to 0.75mg/m2, no further high-grade adverse reactions were observed.
2023-03-02 WBC 5.87 x10^3/uL
2023-02-23 WBC 12.24 x10^3/uL
2023-02-16 WBC 3.07 x10^3/uL
2023-02-13 WBC 4.44 x10^3/uL
2023-02-09 WBC 22.96 x10^3/uL
2023-02-06 WBC 2.70 x10^3/uL
2023-02-03 WBC 2.09 x10^3/uL
2023-02-01 WBC 2.32 x10^3/uL
2023-01-30 WBC 1.66 x10^3/uL
2023-01-27 WBC 0.71 x10^3/uL
2023-01-26 WBC 0.70 x10^3/uL
2023-01-22 WBC 2.41 x10^3/uL
2023-01-16 WBC 5.05 x10^3/uL
2023-03-02 PLT 234 x10^3/uL
2023-02-23 PLT 109 x10^3/uL
2023-02-16 PLT 275 x10^3/uL
2023-02-13 PLT 308 x10^3/uL
2023-02-09 PLT 270 x10^3/uL
2023-02-06 PLT 123 x10^3/uL
2023-02-03 PLT 65 x10^3/uL
2023-02-01 PLT 47 x10^3/uL
2023-01-30 PLT 50 x10^3/uL
2023-01-27 PLT 154 x10^3/uL
2023-01-26 PLT 38 x10^3/uL
2023-01-22 PLT 155 x10^3/uL
2023-01-16 PLT 312 x10^3/uL
S2021-11516A9 (renal pelvic cancer) 2023-01-27 PD-L1 IHC lab results:
PD-L1 expression is not high, suggesting that certain PD-L1 targeted drugs are less likely to be effective against the tumor.
In light of the patient’s diarrhea episodes last month, please keep an eye on her bowel movements. Topotecan is associated with nausea (grade 3/4 8-10%), diarrhea (grade 3/4 6%), and vomiting (grade 3/4 10%). Since the administration days and daily dose of topotecan have been reduced (1.5mg/m2 -> 0.75m2/m2; 5 days -> 3 days), the adverse reaction should be mitigated. As well, Smecta (dioctahedral smectite) 3mg PO PRNTIDAC has been prescribed.
[diagnosis] - 2023-04-27 admission note
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[chemotherapy]
2023-04-21 - docetaxel 30mg/m2 38mg D5W 250mL 1hr + leucovorin 200mg/m2 250mg NS 250mL 2hr + fluorouracil 2000mg/m2 2515mg NS 500mL 24hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 4200mg] IP 1hr (NIPS)
2023-02-14 - oxaliplatin 130mg/m2 150mg D5W 250mL 2hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 2800mg] (with 2023-02-16 ~ 2023-03-14 oral capecitabine)
2023-01-12 - [oxaliplatin 400mg + paclitaxel 120mg + D5W 2500mL] IP 90min
Xeloda (capecitabine 500mg) KXEL)01
[assessment]
Significant weight loss has been observed in the patient, from 43.5kg on 2023-01-06 to 33.3kg on 2023-04-27. Megestrol has been prescribed intermittently between late Dec 2022 and late Feb 2023. If the patient can still tolerate oral intake and there are no contraindications, it may be beneficial to consider adding megestrol back into the patient’s treatment plan to help increase appetite and promote weight gain.
Additionally, providing nutritional support and guidance, including a consultation with a dietician, may further assist in addressing the patient’s weight loss.
The patient has had 7 episodes of diarrhea since 2023-04-26, as noted in the admission record. It is recommended that the number of bowel movements be included in the TPR panel along with the I/O data. If the symptom persists, the addition of loperamide may be beneficial in the management of diarrhea.
Both docetaxel and fluorouracil are associated with diarrhea as a side effect. If diarrhea is suspected to be more related to fluorouracil (2000mg/m2 D1), reducing the dose of fluorouracil (70~80% of the intended dose) at the next treatment may be an option to consider.
[exam findings]
[MedRec]
[chemoimmunotherapy]
[Trimethoprim/Sulfamethoxazole (TMP/SMX) dosing]
Trimethoprim/sulfamethoxazole(TMP/SMX) for patients with moderate to severe Pneumocystis pneumonia infection: IV 15 to 20 mg/kg/day (TMP component) in 3 or 4 divided doses; may switch to oral therapy after clinical improvement.
As recent lab results revealed no abnormalities in the liver and kidney functions, it is less likely that dosage adjustments will be needed.
Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient >= 35 mm Hg) should receive adjunctive glucocorticoids.
{not completed}
[exam findings] (not completed)
[consultation]
[assessment]
AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 275mg) 3# PO QDAC is administered according to the patient’s bone tuberculosis.
It is important to note that the patient is currently taking multiple NSAIDs (Laston (ketorolac) ST, Celebrex (celecoxib) QD, naproxen PRNQ8H). Concomitant use of multiple NSAIDs is not recommended due to the increased risk of side effects such as bleeding and kidney damage. Please monitor the patient closely for signs of bleeding or changes in kidney function and consider adjusting her medication regimen if necessary.
[diagnosis] - 2023-03-29 admission note
[past history] - 2023-03-06 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
2023-04-26 lab results showed low serum Na (133 mmol/L), K (3.4 mmol/L), Mg (1.4 mg/dL), and albumin (3.3 g/dL). These electrolyte imbalances are currently being addressed with appropriate supplementation. With the exception of mild anemia, the patient’s blood cell counts are within normal limits and do not represent a contraindication to the planned chemotherapy.
The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.
Laboratory data on 2023-03-29 showed normal liver/kidney function, however, cation electrolytes and HGB were slightly decreased, which would not contraindicate the planned chemotherapy.
Ascites cytology on 2023-03-08, 2023-03-07, 2023-02-20, 2023-02-17 showed no evidence of positive results.
No medication reconciliation issue identified.
{not completed}
[exam findings]
[surgical operation]
[chemotherapy]
Medication
[assessment]
[past history] - 2023-04-20 admission note
Hypertension for 10 years with regular medication control.
DM with triopathy for 10+ years with regular OHA, insulin control.
Asthma: Asthma since young with regular OPD f/u.
Operation history: Appendectomy 10 yrs ago.
Denied history of Hypertension, DM, asthma
Denied any operation, accident and other medical Hx.
[allergy]
[family history]
[exam findings]
[consultation]
[lab data]
[MedRec]
[assessment]
The patient was diagnosed with rectosigmoid cancer and underwent sigmoidectomy followed by treatment with the FOLFOX regimen in 2020. However, the patient experienced progressive disease. Laparoscopic plevic LND was performed in March 2022, and the patient was subsequently treated with the A-FOLFIRI regimen, but again experienced PD. This time, the patient was admitted to receive the planned FOLFOXIRI regimen.
Flumarin (flomoxef sodium) has been administered since 2023-04-23 to address the elevated sediment WBC and leukocyte esterase in the patient’s urine without issues.
The patient’s platelet count (PLT) has been decreasing over the past three years, with levels not exceeding 100K/uL in 2023. This should be carefully monitored, as it may suggest the presence of undiagnosed underlying conditions that require further evaluation and management.
[diagnosis] - 2023-04-25 admission note
[past history] - 2023-04-25 admission note
DM, HTN, CHF, COPD, Hyperlipidemia, Asthma
[allergy]
[family history]
no hypertension, diabetes mellitus, cancer history
[exam finding]
[consultation]
[MedRec]
[chemoimmunotherapy]
[note]
There is no medication reconciliation issue for the current active formulary, which includes medications prescribed by our cardiologist, pulmonologist, and metabolic specialist.
The patient’s underlying conditions of hypertension (HTN) and type 2 diabetes mellitus (T2DM) are not well controlled during this hospitalization. Blood pressure readings show systolic values between 170 and 184 mmHg, and HbA1c levels have been consistently above 8% for the past 4 months. Serum glucose was recorded as 231mg/dL on the evening of 2023-04-25 and as 158mg/dL on the morning of 2023-04-26. Addition of antihypertensive and/or hypoglycemic agents may be considered if symptoms persist.
[exam findings] (not completed)
[consultation]
[chemotherapy]
2022-09-27 - doxorubicin 60mg/m2 85mg NS 100mL 10min
2022-08-30
2022-08-01
2022-07-01
2022-05-31
2022-01-03 - cisplatin 100mg/m2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1550mg NS 500mL 21hr
2021-11-12 - NS 500mL (before cisplatin) + cisplatin 30mg/m2 40mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
2021-11-05
2021-10-29
2021-05-11
2021-05-04
2021-04-28
2020-11-03
2020-10-27
2020-10-20
[assessment]
On 2023-04-03, a PET scan revealed multiple glucose hypermetabolic lesions in the right supra-renal region, right paraaortic space, bilateral common iliac chains, and soft tissue in the right lower quadrant (RLQ) of the abdomen. These lesions could indicate metastatic disease progression or even another primary malignancy. A CT-guided biopsy of the soft tissue mass in the right lower quadrant of the abdomen is scheduled for 2023-04-25 at 11:00 AM to determine the nature of these lesions.
2023-04-24 eGFR 46. OxyNorm (oxycodone) - CrCl 30 to <60 mL/minute: Immediate release, Oral: Initial: Administer 50% to 75% of usual dose no more frequently than every 6 hours. Use with caution; titrate gradually based on patient response and adverse effects.
[exam findings]
[consultation]
[MedRec]
[diagnosis] - 2023-04-22 discharge note
[exam findings]
2023-03-11 Anoscopy
2023-02-09 2D transthoracic echocardiography
2022-12-22 Nasopharyngoscopy
2022-11-24 2D transthoracic echocardiography
2022-11-17 SONO - abdomen
2022-10-26 PET scan
2022-10-18 Patho - breast mastectomy with regional lymph nodes
2022-10-18 Frozen Section
2022-10-17 Flow Volume Loop
2022-10-07 Patho - breast biopsy (no need margin)
2022-10-07 SONO - breast
2022-10-07 Mammography
2022-08-25 SONO - abdomen
2022-08-11 Nasopharyngoscopy
2022-06-30 ENT Hearing Test
2022-06-08 Neurosonology
2022-06-02 SONO - abdomen
……
……
2017-05-26 Surgical pathology Level VI
2017-05-25 PET scan
2017-05-22 Gynecologic ultrasonography
2017-05-16 Surgical pathology Level IV
2017-05-16 SONO - breast
[consultation]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
2023-04-21 - docetaxel 75mg/m2 110mg NS 250mL 1hr
2023-03-31 - docetaxel 75mg/m2 111mg NS 250mL 1hr
2023-03-10 - docetaxel 75mg/m2 108mg NS 250mL 1hr
2023-03-02 - docetaxel DC (due to WBC 1.57K/uL)
2023-02-09 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 866mg NS 500mL 1hr
2023-01-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr
2022-12-21 - liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 988mg NS 500mL 1hr (2023-01-11 WBC 1.67K/uL)
2022-11-29 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 864mg NS 500mL 1hr
Femara (letrozole) KFEMA01
Granocyte (lenograstim) CGRAN01
Foliromin (ferrous sodium citrate) KFOLIR01
The patient’s HGB levels show a marked downward trend, even though there is no record of blood transfusion. With recent MCV and MCH levels both above the normal range, this macrocytic anemia is less likely to be caused by iron deficiency. The addition of oral Kentamine (vitamin B1, B6, B12) may be helpful.
The development of anemia during chemotherapy suggests that the patient’s HGB levels are not fully recovered at the current dosage, interval, and frequency of the treatment regimen. In cases of severe chemotherapy-induced anemia, blood transfusion is recommended. Another potential option could be to reduce docetaxel from 75mg/m2 to 65mg/m2.
If the patient refuses a blood transfusion, a less optimal alternative may be the use of erythropoiesis-stimulating agents (ESAs). However, it is important to note that ESAs have been associated with shorter overall survival and/or increased risk of tumor progression or recurrence in clinical trials involving patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To minimize these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid red blood cell transfusions. ESAs should only be used for anemia resulting from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the expected outcome is cure. It is also recommended that ESAs be discontinued after completion of chemotherapy.
On 2022-10-28, the multidisciplinary cancer team held a meeting and decided on the following treatment plan for the patient: TC chemotherapy every three weeks for a total of 4 cycles, followed by a CDK4/6 inhibitor (patient self-paid), radiotherapy, and 5 years of hormone therapy.
The patient received 4 cycles of AC (liposome doxorubicin plus cyclophosphamide) on 2022-11-29, 2022-12-21, 2023-01-18, and 2023-02-09. On 2023-01-11, leukopenia occurred with a WBC count of 1.67K/uL, leading to a reduction in liposome doxorubicin dosage from 35mg/m2 to 30mg/m2 for the last two cycles. On 2023-03-02, another leukopenia episode was observed with a WBC count of 1.57K/uL, causing the scheduled docetaxel on that day to be postponed.
The patient’s HGB and PLT levels are showing a obvious decline trend, despite no record of blood transfusion being available. This suggests that under the current dose, interval, and frequency of administration, the patient’s HGB and PLT levels are not able to fully recover.
When severe anemia caused by chemotherapy is present, blood transfusion is recommended. However, if the patient refuses to receive transfusion, a suboptimal option could be to use erythropoiesis-stimulating agents (ESAs). It is important to note that ESAs have been associated with a shortened overall survival and/or an increased risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid RBC transfusions. ESAs should only be used for anemia from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure. It is also suggested to discontinue ESAs following the completion of a chemotherapy course.
[diagnosis] - 2023-03-22 admissiion note
[past history]
The patient had no systemic diseases
History of operation: NIL
Regular medications or herb: no
G2P2
menarche : 16y/o
menopause: 51y/o
Hormone therapy: (-)
Family history of breast cancar: NIL
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[note]
in-hospital “Prescription Collection of Chemotherapy for Breast Cancer” protocol (dated 2022-03-11)
{not completed}
[diagnosis] - 2023-04-21 discharge note
[exam findings]
[lab data]
2021-09-23 EGFR Sample No S21-11584
2021-09-23 EGFR G719X not detected
2021-09-23 EGFR Exon19 del not detected
2021-09-23 EGFR S768I not detected
2021-09-23 EGFR T790M not detected
2021-09-23 EGFR Exon20 ins not detected
2021-09-23 EGFR L858R detected
2021-09-23 EGFR L861Q not detected
[MedRec]
[medication]
[diagnosis] - 2023-04-13 admission note
[present illness] - 2023-04-13 admission note
[past history]
[allergy]
[family history]
1.There is no family history of cancer, hypertension, mental diseases or asthma. 2.No members of the family with diabetes.
[lab data]
2023-04-17 Anti-HCV Nonreactive
2023-04-17 Anti-HCV Value 0.10 S/CO
2023-04-17 Anti-HBc Reactive
2023-04-17 Anti-HBc-Value 4.11 S/CO
2023-04-17 Anti-HBs 774.10 mIU/mL
2023-04-17 HBsAg Nonreactive
2023-04-17 HBsAg (Value) 0.40 S/CO
[chemotherapy]
[assessment]
[exam findings]
[SOAP]
[assessment]
The patient should have been diagnosed with dyslipidemia and hypertension with heart failure, as he has regularly refilled prescriptions for rosuvastatin, valsartan, and spironolactone within the past 3 months, according to PharmaCloud. Additionally, a CT scan on 2023-04-03 revealed extensive 3-vessel coronary artery disease (3V-CAD), indicating significant atherosclerotic plaque in the LAD, LCX, and RCA.
If there are no contraindications, it is recommended to reintroduce these medications and consult a cardiologist to assess whether the patient requires aggressive medical management or revascularization procedures, such as coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI angioplasty with stent placement).
[chief complaint] - 2023-04-17 admission note
[present illness] - 2023-04-17 admission note
The 57 y/o woman has history of hypertension. She had fall down in bus on 2022/11 and then fatigue, vertigo and right hip pain since 2023/01/07, so she bedridden for 3 months. Right breast tumor noted also 3 months. This time, she has dizziness and severe vertigo, so she was brought to our ED for help on 2023/04/17. Her right lower limbs MP down to 3 for 3 months. She denied fever, chills, vomit, SOB or hematuria. At ED, the brain CT showed 1. Mild cortical brain atrophy. 2. Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation? 3. Chronic left mastoiditis. UTI noted from urinalysis. Under the impression of right breast tumor, vertigo, suspect spinal stenosis, so she was admitted on 2023/04/17.
[past history]
[allergy]
[family history]
[exam findings]
[SOAP]
[assessment]
[diagnosis] - 2023-04-12 admission note
[past history]
[family history]
[lab data]
[exam findings]
[surgical operation]
[chemotherapy]
[past history] - 2023-04-13 admission note
OB/GYN history:
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[assessment]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[assessment]
{not completed}
[exam findings]
[consultation]
[chemotherapy]
UFT (tegafur 100mg + Uracil 224mg) KUFT01
[assessment]
[exam findings]
[chemotherapy]
[assessment]
The patient’s serum creatinine has been above 2 mg/dL since 2022Q4 and has not dropped below that level since. The eGFR has been consistently around 30 since 2023.
On 2023-04-13 the following lab results were obtained: HGB 5.1g/dL, Iron bound Fe 22ug/dL, UIBC 145ug/dL, TIBC 146ug/dL, AST 14U/L, and ALT 13U/L. On 2023-04-14, Ferritin was 545ng/mL and Transferrin was 124ng/mL. There is no evidence of iron deficiency or liver dysfunction. Anemia of chronic disease and/or anemia of inflammation might be possible, as well as nutritionally deficiency. The body weight of 36.5 kg recorded on the TPR panel on 2023-04-13 appears to be too low, which may be an erroneous entry.
[diagnosis] - 2022-11-25 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[chemotherapy]
His blood lab data indicated that his ferritin level increased by over 30% in less than 20 days after taking iron supplements from time to time.
High ferritin levels suggest an excess of iron or an acute inflammatory reaction in which ferritin is mobilized without excess iron. Ferritin can be used as an indicator of iron overload disorders, such as hemochromatosis or hemosiderosis. Ferritin can increase the liver proinflammatory mediators IL-1b, iNOS, RANTES, IkappaB alpha, and ICAM1. As ferritin is also an acute-phase reactant, it is often elevated in various diseases. A normal C-reactive protein (CRP) can be used to exclude elevated ferritin caused by acute phase reactions. However, our HIS5 does not contain simultaneous data on ferritin levels and CRP levels.
As the body content of iron (iron burden) increases beyond that needed for normal production of red blood cells, muscle cells, and iron-containing enzymes, the plasma iron-binding protein transferrin becomes saturated, eventually exceeding its capacity and resulting in binding of iron to other proteins and molecules, including albumin, citrate, acetate, and others. This iron is referred to as non-transferrin-bound iron (NTBI); it begins to appear once the transferrin saturation exceeds 35 percent and rises significantly with transferrin saturation above 70 percent. NTBI is taken up by cells that have active uptake mechanisms. This includes parenchymal cells of the liver, heart, and endocrine organs. In these affected organs, excess iron can chemically interact with hydrogen peroxide. These reactive oxygen species in turn can cause tissue damage, inflammation, and fibrosis. The liver, heart, joints, and endocrine organs appear to be especially susceptible.
By the time clinical findings have developed (hepatic fibrosis, heart failure, cardiac conduction defect), it is likely that significant iron deposition and tissue injury has occurred. Please ensure that the patient’s iron level is checked as needed and monitor any signs of iron overload if iron supplements are continued.
The lab data indicated that MCV, MCH, MCHC, UIBC were normal; Ferritin was exceeded; Fe (iron bound) and TIBC was low.
Normal MCV, MCH, MCHC may suggest the anemia is less likely to be caused by iron insufficiency. High ferritin may suggest iron overload. Low TIBC can suggest that there is not enough transferrin available to bind to iron, i.e., the patient has high iron level, so most of the transferrin is bound to it, which leaves very little free in his blood. Frequent blood transfusions may cause iron overload.
It is recommended to hold the Foliromin (ferrous sodium citrate) until the cause of the anemia is confirmed to be iron deficiency.
[diagnosis] - 2023-04-06 admission note
[past history] - 2023-04-06 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP]
[surgical operation]
[chemoimmunotherapy]
2023-03-30 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr D2 (R-GemOx)
2023-02-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2023-01-27 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2023-01-13 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)
2023-01-06 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)
2022-12-29 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)
2022-12-05 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-10-13 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-08-19 - rituximab 375mg/m2 630mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
Tramadol has been associated with vomiting (5% to 10%). ref: UpToDate.
Opioid administration can induce nausea or vomiting; the pathophysiology includes peripheral inhibitory effects of opioids on gastrointestinal transit or stimulation of the pyloric sphincter, delaying gastric emptying or causing gastroparesis. However, the primary mechanism of opioid-induced nausea and vomiting is central, with direct stimulation of the chemoreceptor trigger zone in the area postrema in the floor of the fourth ventricle. The clinical efficacy of 5-HT3 antagonists in opioid-induced emesis supports the hypothesis that stimulation of the area postrema may also be relevant to morphine-induced emesis in humans. The addition of a prokinetic (e.g., metoclopramide), prochlorperazine, or a 5-HT3 antagonist (-setron) to the opiate regimen is beneficial. ref: Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017;15(9):1338-1349. doi:10.1016/j.cgh.2017.05.014
Roumin (prochlorperazine maleate) has been prescribed properly. There is no medication reconciliation issue with the active prescription.
[diagnosis] - 2023-04-14 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP]
[radiotherapy]
[chemotherapy]
[assessment]
[assessment]
[diagnosis] - 2023-04-07 admission note
[exam findings]
[SOAP]
[surgical operation]
[note]
Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer 2023-04-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F89668
Treatment protocols for pancreatic cancer REGIMENS 2023-04-14 https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer
[assessment]
Brosym (cefoperazone + sulbactam) 4g IVD Q12H has been prescribed fot the patient’s BTI.
It is considered to use nab-paclitaxel plus gemcitabine to treat the patient after her BTI is controlled. Please ensure that the ANC is >1500/uL and the platelet count is >100K/uL prior to administering the regimen. Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). During the treatment, it is recommended to initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/uL, then resume at lower doses.
No medication reconciliation issues were noted for the patient.
{not completed}
[past history]
[allergy]
[family history]
[exam findings]
[SOAP]
[assessment]
[diagnosis] - 2023-03-24 admission note
[past history]
Dx history: - Gout - IDA - Alzheimer’s disease - CAD - CVA
Surgery history: - C-spine compression fracture s/p over 10 years ago
[allergy]
[family history]
Father: Liver cancer
[lab data]
[exam findings]
[consultation]
[surigcal operation]
[chemotherapy]
The patient has received a reduced dose of 65mg/m2 of oxaliplatin for the first time during this hospitalization, and no adverse reactions have been observed to date.
For the patient’s chronic viral hepatitis B and post-pancreatico-duodenectomy status, Protase (pancrelipase 280mg) TIDCC and Baraclude (entecavir 0.5mg) QDAC have been prescribed.
There is no medication reconciliation issue found.
[exam findings]
[SOAP]
[chemoimmunotherapy]
[exam findings]
[POMR]
[SOAP]
[chemotherapy]
Induction therapy for acute myeloid leukemia in medically-fit adults. 2023-04-10 https://www.uptodate.com/contents/induction-therapy-for-acute-myeloid-leukemia-in-medically-fit-adults
[follow up]
Bicytopenia progresses, Cravit (levofloxacin) and FLU-D (fluconazole) are used to manage potential infections.
No fever in the past 7 days.
Blast decreased after 7+3 anthracycline plus cytarabine since 2023-03-31.
The patient diagnosed with AML was admitted and received the first dose of “3+7 daunorubicin/cytarabine” regimen on 2023-03-31. Lab data showed the development of severe neutropenia following administration of the regimen.
Treatment with the regimen can cause 3 to 5 weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. And cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.
It is recommended that a bone marrow examination be performed 14 to 21 days after initiation of therapy to assess the initial response to the therapy and to determine if a second induction course is needed.
Initial response to therapy - A bone marrow examination on day 14 of treatment provides an assessment of the clearance of blast cells and a preview of the response to induction therapy. Findings from the day 14 examination may be classified as follows:
Institutions vary in their responses to findings of the day 14 bone marrow examination.
Cravit (levofloxacin) and Flu-D (fluconazole) both have been prescribed to prevent or alleviate the patient from infections. There is no problem that is identified with the active recipe.
{not completed}
[exam findings]
[consultation]
{not completed}
[exam findings]
[consultation]
[lab data]
2023-04-11 Ferritin 1154.7 ng/mL
2023-04-11 Transferrin 143.6 mg/dL
2023-04-11 Fe (Iron-bound) 123 ug/dL
2023-04-11 TIBC 206 ug/dL
2023-04-11 UIBC 83 ug/dL
2023-04-10 BUN 29 mg/dL
2023-04-10 Bilirubin direct 0.22 mg/dL
2023-03-21 Direct Coomb Test Positive
2023-03-21 Indirect Coomb Test Positive
2023-03-21 FKLC 156.0 mg/L
2023-03-21 FLLC 193.0 mg/L
2023-03-17 Anti-beta2-glycoprotein-I Ab 9.2 U/mL
2023-03-17 Gamma 44.3 %
2023-03-15 IgG (blood) 2208 mg/dL
2023-03-09 stool FOB Positive
2023-03-09 Transferrin, stool Postive
[diagnosis] - 2023-04-10 admission note
[past history]
[allergy]
[family history]
[exam findings]
[SOAP]
[chemotherapy]
| he tumor marker CEA was found to be elevated and increasing before the first chemotherapy, and further follow-up tests can be ordered as necessary. |
|---|
| 023-03-08 CEA: 217.89 ng/mL |
The treatment strategy planned on 2023-03-21 is based on the results of PET: if it indicates the presence of metastases, the recommended chemotherapy regimen for concurrent chemoradiotherapy (CCRT) and post-CCRT would be FOLFOX, and total neoadjuvant therapy (TNT) would not be necessary. However, if PET shows that the lesion in the liver is not a metastasis, then the recommended treatment would be TNT, which consists of CCRT with FU, followed by FOLFOX for 6-8 cycles, then surgery and postoperative follow-up. The chemotherapy regimen for CCRT in this case would be FU.
On 2023-03-10, the results of the PET scan were available and the patient began receiving the FOLFOX regimen for the first time while in this hospital stay.
According to the patient’s blood glucose records, there is an upward trend and significant variability in his blood glucose levels despite taking Forxiga (dapagliflozin). To address this, it is recommended to investigate if there has been a significant change in the patient’s dietary intake, especially in regards to carbohydrate consumption, as this could have a substantial impact on blood glucose levels.
[exam findings]
[consultation]
[medication]
[note]
Capecitabine 2023-04-11 https://www.uptodate.com/contents/capecitabine-drug-information
[assessment]
The supplemental report for the IHC staining of EGFR, PMS2, MSH6, MSH2, and MLH1 for the colon biopsy pathology performed on 2023-03-10 is still pending and not yet available.
The patient’s last recorded height on 2023-03-30 is 172 cm, and his last recorded weight on 2023-04-10 is 75.7 kg. Based on these measurements, his body surface area (BSA) is calculated to be 1.9 m2. The patient has been receiving capecitabine at a daily dose of 2000 mg since late March 2023, which is a dose of 1052 mg/m2 based on his BSA. This is approximately 84% of the recommended daily dose of 1250 mg/m2.
It appears that the patient has had anemia even before the administration of capecitabine, and the cause may be gastrointestinal bleeding (in case of A-colon lesions?) as evidenced by positive occult blood in the stool. Blood transfusion performed on 2023-03-07, 2023-03-29, and 2023-04-07 and PPI is currently prescribed.
There is currently no record of hand-and-foot syndrome (HFS) or any related symptoms such as palmar-plantar erythrodysesthesia or chemotherapy-induced acral erythema.
[diagnosis] - 2023-04-02 admission note
[past history] - 2023-04-02 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP}
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient’s sputum Gram’s stain results on 2023-04-02 showed G(+) Cocci 2+, GNB 2+, GPB 3+ (Neutrophil/LPF < 10, Epithelial cell/LPF 15~20). Antibiotics with Betamycin 4.5gm Q6H have been prescribed since the same day to treat the patient’s respiratory symptoms. After checking the PharmaCloud database, no medication reconciliation issue is found.
[ciclosporin TDM]
On 2023-04-08, the patient’s ciclosporin trough concentration was found to be 169ng/mL, which falls within the acceptable range of 100 to 400ng/mL. However, if the target trough concentration is between 200 and 300 ng/mL, then it is recommended to increase the daily dose from the current 200mg to 250mg and continue with regular follow-up testing.
The patient’s kidney function results have returned to normal within the last 7 days.
2023-04-03 Creatinine 0.95 mg/dL
2023-03-31 Creatinine 2.45 mg/dL
2023-03-30 Creatinine 3.10 mg/dL
2023-03-28 Creatinine 3.74 mg/dL
2023-04-03 eGFR 98.94
2023-03-31 eGFR 33.16
2023-03-30 eGFR 25.27
2023-03-28 eGFR 20.35
[cyclosporine IV to PO conversion]
[ciclosporin TDM]
[therapeutic drug monitoring for cyclosporine]
[assessment]
[therapeutic drug monitoring for cyclosporine]
The dose of cyclosporine was increased from the original 140mg to 145mg on a later time on 2023-03-01, and further increased to 170mg on 2023-03-02, while the dosing frequency remained Q12H.
The TDM for cyclosporine was performed on 2023-03-02 at 08:26:39, and the administration time was recorded as 2023-03-02 11:46. The scheduled administration times for Q12H should be 09:00 and 21:00, and the later actual administration time may be due to delayed medication or delayed registration in the system, so it is recommended to confirm the system usage with nursing staff. However, the 08:26 blood draw is consistent with the trough concentration at Q12H.
Since the dose increase has not reached steady state, it is recommended to perform another blood draw in the middle of next week.
[cyclosporine TDM]
[therapeutic drug monitoring]
Sandimmun injection (ciclosporin)
The recommended therapeutic trough concentration range for cyclosporine typically falls within 100-400 ng/mL. The current administration is 140mg IVD Q12H.
Based on the TDM result on 2023-02-23 indicating a level of 43.3 ng/mL, it is suggested to administer a dosage of 180 mg per shot every 12 hours.
It is also recommended to perform another blood test to examine the trough concentration in the latter half of next week.
The echocardiography performed on 2023-01-06 showed an improved LVEF (55% versus 33%) compared to 2022-11-11.
Readings of bilirubin (direct/total) are within normal limits. AST/ALT levels indicate that impaired liver function is improving. There is no need to adjust the dose of medications in the active prescription for liver function. In addition, there is no laboratory evidence of impaired kidney function.
In spite of the fact that Hydrea (hydroxyurea) has been administered since 2023-01-27 afternoon, there has not been an obvious decrease in WBC counts since the second day of administration. The blast percentage remains around 60% with only minor fluctuations.
The PLT count has been trending downward, which should be closely monitored.
The active prescription does not pose a problem.
[drug identification]
We have been requested by the patient’s primary nurse to identify one drug. The drug is identified as Vemlidy (tenofovir alafenamide 25 mg) and is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults and pediatric patients 12 years of age and older with compensated liver disease. The in-hospital porter will return the identified drug to the ward.
Not used:
[exam findings]
[consultation]
[SOAP]
[multiteam]
[diagnosis] - 2023-04-07 discharge note
[exam findings]
[SOAP]
[chemotherapy]
[note]
TPF regimen (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11)
Neoadjuvant Chemotherapy regimen
[assessment]
[exam findings]
[chemotherapy]
[assessment]
Most patients achieve cooling of the oral mucosa through intraoral administration of ice chips during chemotherapy administration. This is a cost effective and proven beneficial treatment.
Both topical and systemic analgesic approaches have been used to manage pain associated with mucositis.
Currently, lidocaine 2% PO PRNQD and tramadol IVD PRNQ6H have been prescribed.
The diet should be limited to foods that do not require significant chewing; acidic, salty, or dry foods should be avoided.
If poor feeding compromises the patient’s nutritional status, placement of a nasogastric feeding tube may be considered.
[diagnosis] - 2023-04-03 discharge note
[lab data]
2023-02-23 HBsAg Nonreactive
2023-02-23 HBsAg (Value) 0.35 S/CO
2023-02-23 Anti-HCV Nonreactive
2023-02-23 Anti-HCV Value 0.07 S/CO
2023-02-23 Anti-HBs 11.15 mIU/mL
2023-02-23 Anti-HBc Reactive
2023-02-23 Anti-HBc-Value 6.43 S/CO
2023-02-23 Anti-HBc IgM Nonreactive
2023-02-23 Anti-HBc IgM Value 0.10 S/CO
2023-02-10 ANA Negative
2023-02-10 LA1 39.3 sec
2023-02-10 LA2 30.7 sec
2023-02-10 LA1/LA2 ratio 1.2
2023-02-08 Anti-Cardiolopin IgG 0.7 GPL-U/mL
2023-02-08 Anti-cardiolipin-IgM <0.8 MPL U/mL
2023-02-08 Anti-β2-glycoprotein-I Ab 0.9 U/mL
2023-02-08 Anti-ENA Sm 1.2 EliA U/ml
2023-02-08 Anti-ENA RNP 1.1 EliA U/ml
[SOAP]
[immunotherapy]
[assessment]
The patient’s PharmaCloud is currently inaccessible. However, based on in-hospital records, the patient received prednisolone at a dose of 80mg daily from 2023-02-08 to 2023-02-22, and dexamethasone at a dose of 8mg daily from 2023-03-10 to 2023-04-07. The patient also received rituximab on 2023-02-23, 2023-03-17, and 2023-04-03.
The peak in PLT count on 2023-03-01 occurred approximately 1 week after the first dose of rituximab and was not during steroid administration. There has been no similar increase since the second dose of rituximab. It is possible that this peak was due to the delayed effect of rituximab, which can take some time for platelet production to increase after treatment. However, without further information, it is difficult to determine the exact cause. Close monitoring of the patient’s platelet levels and response to treatment is recommended.
Lab data from 2023-02-08 and 2023-02-10 showed normal values for ANA, LA1, LA2, LA1/LA2 ratio, anti-cardiolipin IgG, anti-cardiolipin IgM, anti-beta2-glycoprotein-I Ab, anti-ENA Sm, anti-ENA RNP, and PT, INR, APTT.
In the event that rituximab is no longer effective, splenectomy or TPO-RAs may be considered options.
{EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB - not completed}
[diagnosis] - 2023-04-02 admission note
[past history]
[allergy]
[family history]
[exam findings]
EGFR wild type Adenocarcinoma of RUL with liver metastases,T4N0M1c,stageIVB
Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
Chest CT without IV contrast ehnancement shows: Chest: S/p port-A placement with its tip at Superior vena cava. Massive bilateral pleural effuison and loculated effusion at right hemithorax is found. Patent airway is found. There is no evidence of mediastinal LAP
Visible abdomen: Atrophy of both kidneys are found. The GB is well distended without soft tissue lesion The spleen, pancreas and adrenals are intact. Low density lesion at S4 and S2 of liver is found. Liver meta is considered. In comparison with CT dated on 2022-09-28, regression of the tumor is found. There is no evidence of paraarotic LAPs. There is no ascites accumulation at abdominal cavity. Suggest clinical correlation
Imp: Loculated effusion at both hemithorax. Liver tumor, in regression.
History:眩暈,想吐,表偶爾會流鼻水,有血絲 Nausea without vomit for 2-3 days, mild dizziness SOB sometimes, very mild Abd distension since last chemo(6 days ago) 20220705 CT：RUL lung ca & liver mets;T3N2M1c, cSTAGE:IVB
MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
Findings: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. There are bilateral extensive destructive centrilobular emphysema with upper lobes predominant. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT. 3. Prior CT identified few cysts in S1 and S2 are noted again, stationary. 4. There are several renal stones, bilateral. Both kidney show small size and thin parenchyma that are c/w chronic renal disease. 5. There is no hyper-or hypodense lesion in the gallbladder, biliary system, pancreas, and spleen. There is no ascites or lymphadenopathy. There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable. There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
IMP: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT.
[SOAP]
[chemotherapy] (not completed)
2023-01-05 - docetaxel 35mg/m2 54mg D5W 150mL 1hr (WBC 1.3K/uL 2023-01-12, WBC 2.15K/uL 2023-01-14)
2022-12-15 - ditto (WBC 1.87K/uL 2022-12-22, WBC 1.42K/uL 2022-12-26)
2022-12-01 - ditto (WBC 2.54K/uL 2022-12-13)
2022-11-15 - ditto (WBC 2.67K/uL 2022-11-29)
2022-11-03 - ditto
2022-10-25 - ditto
2022-10-18 - ditto
2022-10-06 - ditto
2022-09-22 - ditto
2022-09-15 - ditto
2022-09-01 - ditto
2022-08-25 - ditto
2022-08-10 - ditto
2022-07-19 - pemetrexed 500mg/m2 818mg NS 100mL 10min + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)
[medication]
[assessment]
[diagnosis] - 2023-04-02 admission note
[past history]
[allergy]
[family history]
[lab data]
2023-04-03 HBsAg Nonreactive
2023-04-03 HBsAg (Value) 0.52 S/CO
2023-04-03 Anti-HBc Nonreactive
2023-04-03 Anti-HBc-Value 0.91 S/CO
2023-04-03 Anti-HCV Nonreactive
2023-04-03 Anti-HCV Value 0.05 S/CO
2023-04-03 Anti HTLV I/II Nonreactive
2023-04-03 Anti HTLV I/II Value 0.05 S/CO
2023-04-03 HIV Ab-EIA Nonreactive
2023-04-03 Anti-HIV Value 0.06 S/CO
2023-04-03 CMV_IgG Reactive
2023-04-03 CMV_IgG Value 213.4 AU/mL
2023-04-03 CMV IgM Nonreactive
2023-04-03 CMV IgM Value 0.23 Index
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy] (not completed)
[note]
Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (ref: https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)
[diagnosis] - 2023-04-01 admisstion note
[present illness] - 2023-04-01 admisstion note
[exam findings]
[SOAP]
[assessment]
The patient’s fever appears to have improved (with a temperature not exceeding 37.5 degrees Celsius) since the administration of Flumarin (flomoxef) on 2023-04-01. However, blood and urine cultures are not yet available.
The patient has a high bilirubin level and is icteric 2+. The elevation of serum alkaline phosphatase, which is out of proportion to the serum aminotransferases, indicates possible biliary obstruction or intrahepatic cholestasis. An increased serum alkaline phosphatase is also observed in granulomatous liver diseases, such as tuberculosis or sarcoidosis.
Based on the CT performed on 2023-04-01, there is evidence of liver, lung, lymph node metastasis, and peritoneal carcinomatosis. Further evaluation is recommended, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) to investigate the presence of intra- or extrahepatic bile duct dilation.
The patient was prescribed Vemlidy (tenofovir alafenamide) appropriately following a positive anti-HBc test result on 2023-03-14.
According to PharmaCloud records, medications were prescribed for pulmonary symptoms at Cardinal Tien Hospital in January 2023. If these symptoms are no longer present, then there are no medication reconciliation issues.
[diagnosis] - 2023-03-30 admission note
[exam findings]
[assessment]
[diagnosis] - 2023-03-10 discharge note
[exam findings]
[consultation]
[SDM] - 2023-02-02
[surgical operation]
[chemotherapy]
Induction chemotherapy should be used when chemotherapy occurs before radiation therapy. The term neoadjuvant chemotherapy should be used to refer to chemotherapy before surgery. ref: https://www.healthline.com/health/cancer/induction-chemotherapy
[assessment]
The patient has received (planned total 9-dose) TPF neoadjuvant regimen on 6 occasions, specifically on 2023-02-03, 2023-02-13, 2023-02-27, 2023-03-06, 2023-03-22, and 2023-03-31 (the 6th time during this hospitalization). There was only one episode of WBC less than 3K/uL, which occurred on 2023-02-10, approximately 1 week after the first dose. Otherwise, no other episodes of low WBC count were observed.
The TPF regimen was appropriately dose reduced from the second dose, with docetaxel at 32mg/m2 instead of 40mg/m2, cisplatin at 32mg/m2 instead of 40mg/m2, and fluorouracil at 900-800mg/m2 instead of 1000mg/m2. G-CSF was also used in a timely manner.
According to the latest information, there are no moderate or severe complaints for the patient about adverse reactions.
By the way, there is a decreasing trend in HGB, which indicates that the HGB does not seem to be fully recovered at the current administration interval/frequency. Please continue monitoring and check for need for blood transfusion for the next 3 scheduled doses.
[diagnosis] - 2023-03-09 admission note
[lab data]
[exam findings]
[consultation]
[SOAP]
[chemotherapy]
2023-03-30 CRP 18.82mg/dL, WBC 12.95K/uL, urine bacteria 1+, urine protein 1+. Blood culture results are not yet available.
There have been no medication reconciliation issues found in the patient. (PharmaCloud not accessible)
[present illness] - 2023-03-29 admission note
This is 77-year-old man who has past medical history of Raynaud phenomenon, Diabetes Type II, right lung adenocarcioma RLL status post VATS wedge resection, prostatic cancer status post TURP under regular oral endoxan and prednisolone. This time, he complained of dyspnea for days, OPD CXR showed right pleural effusion. Loss 5 kg due to poor appetite in one month according to himself. He was admitted to our ward for further evalation and treatment.
[past history]
[allergy]
[family history]
[SOAP]
[medication]
[assessment]
[diagnosis] - 2023-03-06 admission note
[past history]
Heart:(-)
Liver:(-)
Kidney:(-)
H/T:(-)
DM:(-) Other
DVT 2 years ago
medication: Rivaroxaban regularly and had taken Leuplin
Surgical: denied
Menstrual history: G0P0, Last menstrual period: 2022-09-25
sex –
Menarche at the age of 12 years old
Menstrual cycle:irregular with duration of 7 days
Amount: moderate with blood clots
Pap smear: denied
[allergy]
[family history]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]
On 2023-03-29, the patient’s lab results indicated generally normal blood cell counts, selected electrolytes, and liver/kidney functions. There is no evidence that contraindicates the scheduled chemotherapy. The patient was diagnosed with acute embolism and thrombosis of the femoral and iliac veins on 2020-11-16 and has been taking Xarelto (rivaroxaban) for this condition. After reviewing the PharmaCloud database, no medication reconciliation issues were identified.
After a leukopenia event (WBC 1.65K/uL on 2022-12-31), all subsequent data showed WBC counts above 5K/uL. Since receiving paclitaxel + carboplatin regimen in late November 2022, there have been no observations of anemia and/or thrombocytopenia. The patient is currently taking rivaroxaban as a self-carried medication due to a history of DVT. No medication reconciliation issues were found during this hospital stay.
Based on the lab results (2022-12-19), the scheduled chemotherapy did not appear to be contraindicated.
[diagnosis] - 2023-03-03 admission note
[past history]
[allergy]
[family history]
[exam findings]
Right liver cysts (3.57x4.19cm, 1.26x1.32cm).
Gallbladder stones (3-5mm).
2023-01-06 SONO - thyroid gland.
2023-01-06, 2022-12-02, -10-28 Nasopharyngoscopy
2022-11-24 Gynecologic ultrasonography
2022-11-16 CT - abdomen
2022-09-08 MRI - nasopharynx
2022-09-01, -06-02 SONO - abdomen
2022-06-14 ECG
2022-06-14 CXR
2022-06-14 PTA
2022-04-28 Tc-99m MDP whole body bone scan
2022-04-28 Gynecologic ultrasonography
2022-04-27 Panendoscopy
2022-04-27 SONO - abdomen
2022-04-26 MRI - nasopharynx
2022-04-26 PTA
2022-04-25 ECG
2022-04-18 PTA
2022-04-11 Patho - nasopharyngeal/oropharyngeal biopsy
2022-04-11 Otologic endoscopy
2022-04-11 Nasopharyngoscopy
2022-03-12 SONO - abdomen
2020-12-16 2D transthoracic echocardiography
[SOAP]
[radiotherapy]
[chemoimmunotherapy]
The patient was prescribed ergometrine maleate for an unspecified leiomyoma of uterus by our gynecologist on 2023-03-03. However, this drug is not currently shown in the active medication list. It has no known interaction with the patient’s current medications. Therefore, adding it as a self-carried item to the active medication list is recommended for proper medication reconciliation.
In addition, it is noted that fluorouracil, metoclopramide, and hydroxychloroquine are potential QT-prolonging agents. Administration of these drugs in an overlapping manner may enhance the QTc-prolonging effect, which should be monitored.
[exam findings]
[SOAP]
[radiotherapy]
[chemotherapy]
[assessment]
The patient was diagnosed with low rectal cancer involving the anal canal with bleeding, cT4bN1bM0, stage: IIIC.
For patients with locally advanced rectal cancer who are at high risk for a margin-positive resection or node-positive disease with a low-lying rectal tumor, total neoadjuvant therapy (TNT) is suggested instead of long-course CRT or short-course RT alone. TNT combines oxaliplatin-based chemotherapy with long-course CRT or short-course RT, leading to increased chemotherapy compliance, improved local control, and the ability to consider nonoperative treatment if the patient declines surgery.
The patient has been admitted to receive her first dose of FOLFOX. Lab results on 2023-03-23 showed normal liver and kidney function, blood cell counts, serum electrolytes, and no contraindications to chemotherapy.
The patient’s chronic viral hepatitis B without the delta agent is currently being managed with Baraclude (entecavir).
The current active prescription has no identified issues.
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[assessment]
The patient experienced nadir levels in her WBC and/or PLT count approximately one week after receiving chemotherapy, as indicated by asterisks in the table below (WBC < 3K/uL, PLT < 100K/uL).
The patient was admitted for her scheduled chemotherapy with a 20% dose reduction of paclitaxel due to her not fully recovered low PLT level.
No medication reconciliation issues were found after reviewing PharmaCloud and comparing it to the active prescription.
[exam findings]
[assessment]
[past history] - 2023-03-25 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP]
[chemotherapy]
[medication]
[assessment]
[diagnosis] - 2023-03-27 admission note
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
The patient underwent surgery for feeding jejunostomy and port-A placement on 2023-02-20 and she began receiving cisplatin and fluorouracil starting from 2023-02-27.
Patients who have undergone feeding jejunostomy surgery often require additional nutritional support and close monitoring of their hydration status. All the oral drugs in the current prescription are compatible with tube feeding.
[diagnosis] - 2023-03-27 admission note
[past history]
[allergy]
[family history]
[exam findings]
[surigcal operation]
[chemoimmunotherapy]
2023-03-27 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOXIRI)
2023-03-01 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOXIRI)
2023-02-07 (Avastin + FOLFOX)
2023-01-09 (Avastin + FOLFOX)
2022-12-12 (Avastin + FOLFOX)
2022-11-18 (Avastin + FOLFOX)
2022-10-26 (Avastin + FOLFOX)
2022-07-04 (Avastin + FOLFIRI)
2022-06-08 (Avastin + FOLFIRI)
2022-05-16 (Avastin + FOLFIRI)
2022-04-20 (Avastin + FOLFIRI)
2022-03-29 (Avastin + FOLFIRI)
2022-03-04 (Avastin + FOLFIRI)
2022-02-11 (Avastin + FOLFIRI)
2022-01-12 (Avastin + FOLFIRI)
2021-12-27 (Avastin + FOLFIRI)
[assessment]
[diagnosis] - 2023-03-28 discharge note
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
{Chronic myelomonocytic leukemia, CMMoL}
[ciclosporin TDM]
Based on the available system records, the blood for ciclosporin was drawn at 00:48 on 2023-03-27, approximately 4 hours after medication administration at 20:32 on 2023-03-26. If the purpose of the blood draw was to measure the trough concentration, the ideal time to draw blood is within 30 minutes before next scheduled medication administration. Therefore, it is recommended to verify the accuracy of the system records or to redraw a blood sample at the appropriate time for accurate measurement.
The recorded concentration result for ciclosporin is 331.4ng/mL, but its accuracy as a trough level may be questionable due to the possibility of an inappropriate blood draw time.
The peak concentration of cyclosporine-A was 326 ng/mL on 2022-12-12, which is within the normal therapeutic range.
2022-12-13 WBC 670/uL, PLT 2000/uL.
[cyclosporine trough concentration]
As a follow-up of the change in dose of cyclosporine from 100mg Q12H to 120mg Q12H since 2022-11-25, it is recommended that the trough concentration of cyclosporine be renewed by drawing blood within 30 minutes of the first dose on 2022-11-29.
[cyclosporine trough concentration]
Following the administration of 100 mg Q12H since 2022-11-21, a blood sample was taken for cyclosporine trough concentration, and the level was 63.9 ng/mL. In general, the effective range is considered to be between 100 and 400 ng/mL. In the event that the clinical effect not shown, increasing the daily dose to 300mg (divided in 3 seperate administration) can be considered and then recheck the trough concentration 3 days after the dose alteration. The goal is to limit the concentration with a minimum dose while retaining the necessary clinical effect.
According to UpToDate database, cyclosporine for patients with altered kidney function, CrCl <60 mL/minute: No dosage adjustment necessary (0.1% excreted in the urine unchanged) (Nemecek 2019; expert opinion). For nontransplant indications (eg, autoimmune disease), the manufacturer’s labeling states use is contraindicated in patients with abnormal renal function (not defined); however, when potential benefits outweigh the risks, may consider cautious use with frequent monitoring of kidney function, or consider use of an alternative agent due to increased risk of worsening kidney function, especially for patients with more severe impairment (expert opinion).
2022-10-20 eGFR 35. The dosage of prescribed drugs is within the recommended range for patients with altered kidney function.
[Diagnosis] - 2023-03-27 admission note
[present illness] - 2023-03-27 admission note
[past history] - 2023-03-27 admission note
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemotherapy]
[assessment]
[diagnosis] - 2023-03-13 admission note
[past history]
[allergy]
[family history]
[exam findings]
MRI (111-2-5, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. focal area 39.5mm in the surgical margins is noted; the lesion was not identified on MR 2020/9/8; new recurrent tumor is considered. (arrow key images) 3. hepatic veins and portal veins are patent 4. there are no focal lesions in the spleen pancreas both adrenal and kidneys; a tiny cyst in the left kidney; 5. there is no evidence of paraaortic LAPs in abdomen; there is no evidence of paraaortic LAPs in pelvic cavity and bilateral inguingal areas. 6. there is no ascites 7. enlarged prostate is noted with posterior urinary bladder indentation; 8. hydrocele of the left scrotum. PET (111-3-2, NTUH): Some intense hot areas along medial border of the liver (figures 1-1 to 1-4, SUVmax=11.85). * Some moderate hot spots at abdominal paraaortic nodes and left iliac nodes (figures 1-5 to 1-9, SUVmax=5.79). * A faint hot spot at right iliac crest (figure 1-10, SUVmax=1.34), probably benign. * Some mild hot areas at L1-L2 vertebral junction, right hip joint, and right ischial enthesis, probably arthritis and enthesitis. * Intense curvilinear-shaped hot areas at bowel loops, suspicious Metformin-related activity. Pathology (P2202854, 2022-3-26, NTUH): Liver segment 5 8 anatomical hepatectomy cholangiocarcinoma Gallbladder cholecystectomy chronic cholecystitis Lymph node peri-gallbladder lymphadenectomy minimal histological change (1/1). Histologic Grade Grade 2: Moderately differentiated (50% to 95% of tumor composed of glands). Margins (check all that apply) Hepatic Parenchymal Margin Uninvolved by invasive carcinoma. Lymph-Vascular Invasion: not identified. Perineural Invasion Not identified. Pathologic Staging (pTNM according to AJCC v.8): Primary Tumor (pT) pT1b: Solitary tumor ＞5cm without vascular invasion Regional Lymph Nodes (pN) pN0: No regional lymph node metastasis. MRI (111-5-4, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. operative change of the anterior right lobe of liver; no evidence of local residual tumor is noted; a small biloma. 3. a recurrent tumor 34.5mm is noted at the S1 of the liver; cholangiocarcinoma is considered. 4. hepatic veins and portal veins are patent 5. there are no focal lesions in the spleen pancreas both adrenal and kidneys 6. there is no evidence of paraaortic LAPs in abdomen 7. there is no ascites
[consultation]
[radiotherapy]
[chemotherapy]
[exam findings]
[consultation]
[chemotherapy]
[exam findings]
[consultation]
[cancer multidisciplinary team meeting conclusion] - meeting date: 20221111
[chemoimmunotherapy]
[mucositis]
As of now, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available in this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).
{not completed}
[diagnosis] - 2023-03-22 admission note
[past history]
Irregular drug use
[allergy]
[family history]
[exam findings]
[consultation, not completed]
[radiotheray]
[chemotherapy]
[assessment]
[diagnosis] - 2023-03-22 admission note
[past history] - 20221213 admission note
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[assessment 2023-01-14, not posted]
[assessment]
The patient had developed tinea unguium in Jan 2023, but there is no longer any evidence of the condition in the updated medical records.
The patient is currently admitted for his 10th cycle of Avastin + FOLFIRI chemoimmunotherapy, and it is planned that he will receive a total of 12 cycles. His liver and kidney function, as well as his electrolyte levels, are normal, although there is a slight anemia based on the 2023-03-21 lab results.
There were no medication reconciliation issues found in the patient.
CT results from 2023-01-31 indicate the presence of focal peritoneal infiltrates, which could suggest post-operative changes or disease recurrence. Further diagnostic tests or imaging studies may be necessary to make a definitive diagnosis and determine whether new treatment should be planned.
{not completed}
[exam findings]
[consultation]
[multiteam]
[surgical operation]
[radiotherapy]
[chemotherapy]
PharmaCloud database reports that Natrilix (indapamide) has been prescribed at VGHTPE on 2022-12-29 as a 84-day refillable prescription, along with other medications such as Norvasc (amlodipine), Betaloc (metoprolol), and Olmetec (olmesartan) to manage the patient’s hypertension. And this patient developed hyponatremia since 2023-02.
Indapamide is a type of diuretic known as a low-ceiling diuretic, which functions by inhibiting the sodium-chloride co-transporter in the kidneys. This leads to an increase in the excretion of both sodium and water from the body.
Treatment of diuretic-induced hyponatremia consists of discontinuing the diuretic and administering either isotonic saline or, if the hyponatremia is severe or symptomatic, hypertonic saline. There is a potential risk of overly rapid correction of the hyponatremia with either regimen. Once the diuretic has been cleared and the patient becomes euvolemic, antidiuretic hormone (ADH) release will be appropriately suppressed, resulting in the excretion of a dilute urine, which can lead to rapid excretion of the excess water. Thus, patients with moderate to severe hyponatremia must be monitored carefully during treatment to minimize the risk of osmotic demyelination.
It is recommended to monitor serum Na levels at a frequency no less than every 12 hours, ensuring that any changes in serum Na levels do not exceed 4-6mEq/L within a 24-hour period to avoid the development of osmotic demyelination syndrome (ODS). Additionally, it is advised to monitor urine output and neurological symptoms. Other recommended tests include checking serum osmolality, TSH, free T4, ACTH (at 8 am), cortisol (at 8 am), urine osmolality, Na, and Cre.
[exam findings]
[consultation]
[exam findings]
[consultation]
[assessment]
{Metastatic colon adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA, post segmental hepatectomy on 2019-06-05}
[diagnosis] - 2023-03-20 admission note
[past history] - 2022-11-25 admission note
[family history]
[lab data]
[exam findings]
A metastasis 3.9 x 2 cm in S7 of the liver S/P C/T with stable disease.
2019-11-21 Whole body PET scan
2019-11-11 CT - abdomen
2019-08-14 Tc-99m MDP whole body bone scan
2019-08-03 MRI - liver, spleen
2019-06-06 Surgical pathology Level V
2019-06-08 CT - abdomen
2019-05-20 CT - abdomen
2018-11-16 CT
2018-07-07 CT
2018-06-28 Surgical pathology Level III
2018-04-26 Surgical pathology Level VI
[consultation]
[surgical operation]
[chemotherapy]
dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
2022-11-25 - cetuximab 250mg/m2 480mg 2hr + oxaliplatin 60mg/m2 115mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5450mg 46hr (FOLFOXIRI Zhang_ShouYi)
2022-11-08 - cetuximab 250mg/m2 490mg 2hr + oxaliplatin 60mg/m2 118mg 2hr + irinotecan 150mg/m2 295mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-10-20 - cetuximab 250mg/m2 485mg 2hr + oxaliplatin 60mg/m2 116mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 775mg 2hr + 5-Fu 2800mg/m2 5430mg 46hr (Zhang_ShouYi)
2022-08-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 180mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2022-09-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2022-08-26 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5520mg 46hr (Zhang_ShouYi) patient asked to add oxaliplatin back.
2022-08-12 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-07-21 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2022-07-01 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2022-06-14 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi) FOLFIRI
2022-05-24 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 185mg/m2 370mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2022-04-27 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-03-29 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-03-15 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-02-10 - cetuximab 400mg/m2 700mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-01-14 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2021-12-22 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 160mg/m2 300mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)
2021-12-01 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)
2021-11-11 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5345mg 46hr (Zhang_ShouYi) FOLFOXIRI
2021-09-28 ~ 2021-11-09 - Stivarga (regorafenib 40mg/tab) 4# QD D1-21 Q4W
2021-09-03 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2021-08-20 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5640mg 46hr (Zhang_ShouYi)
2021-07-29 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 805mg 2hr + 5-Fu 2800mg/m2 5660mg 46hr (Zhang_ShouYi)
2020-08-24 - bevacizumab 5mg/kg 200mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2020-07-27 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)
2020-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5460mg 46hr (Zhang_ShouYi)
2020-06-15 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2020-05-28 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 160mg/m2 300mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2020-05-07 - bevacizumab 300mg 90min + irinotecan 120mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + 5-Fu 400mg/m2 650mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1-2 (Liu_JunHuang)
2020-04-20 - bevacizumab 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 560mg 2hr + 5-Fu 400mg/m2 560mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1 (Liu_JunHuang)
2020-04-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1 (Liu_JunHuang)
2020-03-16 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-03-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-02-17 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-02-03 - irinotecan 270mg 1.5hr + leucovorin 400mg/m2 760mg 0hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-01-13 - oxaliplatin 85mg/m2 2hr + leucovorin 200mg/m2 380mg 0hr + 5-Fu 400mg/m2 684mg 15min D1-2 + 5-FU 1000 mg 20hr D1-2 (Liu_JunHuang)
2019-12-06 ~ 2019-12-28 - capecitabine
2019-06-12 - FOLFIRI + bevacizumab
2019-05-28 - FOLFIRI + bevacizumab
2019-05-07 - FOLFIRI + bevacizumab
2019-04-20 - FOLFIRI + bevacizumab
2019-04-03 - FOLFIRI + bevacizumab
2019-03-16 - FOLFIRI + bevacizumab
2019-03-02 - FOLFIRI + bevacizumab
2019-02-17 - FOLFIRI + bevacizumab
2019-02-03 - FOLFIRI
2019-01-03 - FOLFIRI
2018-06-08 ~ 2018-06-18: capecitabine
The control of blood sugar is better than it was during the last hospital stay. As far as the active prescription is concerned, there is no problem.
The patient continues to have poor blood sugar control despite treatment with acarbose, metformin, and vildagliptin (2 data points over 244 mg/dL on 2022-11-08 and 2022-11-09). SGLT2 inhibitors such as Canaglu (canagliflozin), Forxiga (dapagliflozin) or Jardiance (empagliflozin) might be added to help manage diabetes.
Although the patient is currently receiving 3 classes of oral antidiabetic medications (metformin, sitagliptin, and dapagliflozin), his blood sugar remains high (381mg/dL on 2022-09-12 17:35, 302mg/dL on 2022-09-13 06:46); HbA1c of 8.4 (2022-08-26 lab), mild diabetic retinopathy has been confirmed (2022-03-15 ophthalmology).
Starting basal insulin (e.g., Toujeo (insulin glargine)) at 0.1 unit/kg/day or 10 units/day is recommended.
Irinotecan 180 mg/m2 in current regimen is considered a normal dose range for patients with ALT/AST 43/44, BUN 10 (2022-07-21).
There is a history of T2DM in this patient. The most recent HbA1c record dates from 2019, and the AC blood sugar readings have been 271, 327, and 267 since this hospitalization. As there is no hypoglycemic agent in active prescriptions, metformin 500 mg BID is recommended.
CT and MRI in mid January 2022 showed the disease progressed compared to previous images.
CEA readings since July 2021 at intervals of two to three months showed a peak in November 2021 (1261ng/mL) and a slight fall in February 2022 (886ng/mL), possibly caused by the introduction of FOLFOXIRI from November 2021 (ongoing).
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemotherapy]
[note]
First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer https://www.uptodate.com/contents/first-line-chemotherapy-for-advanced-stage-iii-or-iv-epithelial-ovarian-fallopian-tube-and-peritoneal-cancer
{not completed}
He was admitted for hemoptysis with blood clot from oral and nasal cavity for more than a week. History of NPC and CT imaging revealed possible tumor recurrence in Jan 2022.
[exam findings]
[consultation]
2023-03-17 Ear Nose Throat
2023-03-17 Infectious Disease
surgical operation
[drug identification]
The medication you are requesting drug identification for is Eltroxin, which contains levothyroxine at a dose of 0.05mg.
This medication is used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone.
The medication will be sent back to the ward by an in-hospital porter.
[diagnosis] - 2023-03-17 admission note
[exam findings]
[consultation]
[surgical operation]
[C/T history]
C1D1 (#1) HD-MTX (8000mg/m2) on 2022/7/14, C1D2 Leucovorin (100 mg/m2) q6h until serum methotrexate <0.05 mmol/L and C1D3 Mabthera (375mg/m2) = 750mg on 2022/7/16. Rolican + HS hydration for AKI correct after HD-MTX. Feburic 80mg/tab (Febuxostat) 1# qod for prevent elevated uric acid.
C1D14 (#2) HD-MTX (due to AKI history, so change to 4000mg/m2) on 22022/8/09, Leucovorin 100mg q6h, Mabthera on 2022/8/11. Colchine and dexamethaxone for gouty arthritis treatment on 2022/8/17.
C2D1 (#3) HD-MTX (4g/m2), Covorin, Mabthera on 2022/8/24-8/26. C2D14(#4) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/12-9/14. C3D1 (#5) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/26-9/28.
2022/10/13 brain MRI: 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe. C3D15 (#6) HD-MTX (8g/m2), Covorin, Mabthera on 2022/10/21-23.
He received the radiotherapy on 2022/11/2 -2022/12/6 with 3060cGy/17 fractions ofthe whole brain, and 4500cGy/25 fractions of the CNS lymphoma area.
C4D1 (#7) HD-MTX (8g/m2), Covorin,Mabthera on 2023/1/6-8. Followed up MRI of brain was performed on 2023/2/8 revealed No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.
This time, he was admitted for C4D15 (#8) chemotherapy HD MTX/Covorin/Mabthera on 2023/3/17.
[chemoimmunotherapy]
[dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2
2022-10-21 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3
2022-09-26 - methotrexate 4000mg/m2 7950mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3
2022-09-12 - methotrexate 4000mg/m2 7980mg 6hr D1 + rituximab 375mg/m2 748mg 8hr D3
2022-08-24 - methotrexate 4000mg/m2 7880mg 6hr D1 + rituximab 375mg/m2 740mg 8hr D3
2022-08-09 - methotrexate 4000mg/m2 7900mg 6hr D1 + rituximab 375mg/m2 744mg 8hr D3
2022-07-14 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 750mg 8hr D3
[note]
methotrexate (https://www.uptodate.com/contents/methotrexate-drug-information 2022-07-20)
leucovorin (https://www.uptodate.com/contents/leucovorin-drug-information 2022-07-20)
Methotrexate induced acute renal failure is typically nonoliguric and is reversible in almost all cases. Plasma creatinine levels usually peak within the first week and return toward baseline levels within 1 to 3 weeks. The patient’s renal function is decreasing at a much slower rate over time, which is a positive sign that creatinine almost reaches its peak level.
The likelihood of MTX-induced renal dysfunction in patients receiving high dose MTX can be minimized (but not eliminated) by hydration both to maintain a high urine flow and to lower the concentration of MTX in the tubular fluid and by alkalinization of the urine to a pH above 7.0. Raising the urine pH from 5.0 to 7.0 increases the solubility of MTX 10-fold.
It is customary to begin the MTX infusion only after the urine pH is >= 7.0 and to maintain it in this range until plasma MTX levels have declined to less than 0.1 microM.
Urinary alkalinization is most easily accomplished by adding ampules of sodium bicarbonate to each liter of IV fluid hydration. This accomplishes both fluid hydration and urinary alkalinization. A typical choice is IV D5W with 100 to 150 mEq of sodium bicarbonate per liter, administered by continuous infusion at 125 to 150 mL/hour. A cation concentration of 80.5 mEq/L is roughly equivalent to one-half normal saline. The amount of bicarbonate in each liter and the IV fluid composition can then be modified according to the urine pH and serum sodium.
An alternative oral protocol for sodium bicarbonate can be started with 3000 mg (300mg/tab * 10 tablets) Q6H, and can be escalated the frequency to Q4H as needed; once the urine pH is greater than 7, the 24 hour daily dose can then be lowered and divided into four doses, every six hours.
Lab data indicated that the patient’s renal function is deterioating
In this male patient, who is 56 y/o, Cre 2.02 mg/dL and weighs 82 kg, the estimated CrCl is 47 mL/min. The self-carried Baraclude (entecavir) for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours. QODAC is preferred.
Methotrexate is greater 80% excreted as the unchanged drug and is primarily excreted in the urine. Leucovorin 100mg IVD Q6H has been administered since 2023-01-08 06:05.
Serum MTX levels are declining at an apparent rate.
If the patient is still able to urinate normally, furosemide may be an option for helping the excretion of methotrexate. For patients with an eGFR greater than 30 mL/minute/1.73m2, furosemide does not require dosage adjustment.
[lab data]
2023-03-17 Anti-HBc Nonreactive
2023-03-17 Anti-HBc-Value 0.18 S/CO
2023-03-17 Anti-HCV Nonreactive
2023-03-17 Anti-HCV Value 0.17 S/CO
2023-02-03 Anti-HCV Nonreactive
2023-02-03 Anti-HCV Value 0.10 S/CO
2023-02-03 HBsAg Nonreactive
2023-02-03 HBsAg (Value) 0.49 S/CO
2023-02-03 Anti-HBs 1.12 mIU/mL
2023-02-02 MTBC PCR NOT DETECTED
2023-02-02 MTBC PCR Value <11.8 CFU/ml
[exam findings]
[radiotherapy]
[chemotherapy]
[drug interaction]
Histamine H2 Receptor Antagonists may decrease the absorption of dasatinib. Dasatinib prescribing information states histamine H2 receptor antagonists (H2RAs) should not be coadministered with dasatinib due to the risk of reduced dasatinib concentrations and efficacy. Given the longer-term acid suppression achieved with H2-antagonist or proton pump inhibitor therapy, the manufacturer suggests the use of antacids (with 2-hour dose separation) if acid-reducing therapy is required. The likely mechanism for this apparent interaction is impaired absorption of dasatinib, which does appear to display pH-sensitive solubility, due to the increase in gastric pH caused by a H2-receptor antagonist.
Currently, the patient is prescribed Sprycel (dasatinib) and Ulstop (famotidine) with a QD and BID frequency, respectively. These medications are being administered at the same time of 09:00. To prevent any potential drug interactions, it is recommended to shift the administration time of one of the medications to a time that does not overlap with the other medication.
[exam findings]
[chemotherapy]
Granocyte (lenograstim 250ug/vial) CGRAN01 - 2023-03-02 ~ 2023-03-04 - 250ug QD SC - IPD 2023-03-02
[assessment]
{Malignant neoplasm of body of stomach; gastric antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy}
[diagnosis] - 2023-02-04 discharge note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
2023-01-09 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr
2022-12-22 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2400mg/m2 2840mg 46hr
2022-12-08 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr
2022-11-17 - oxaliplatin 40mg/m2 47mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2360mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-10-25 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2370mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-09-13 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-08-30 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-08-08 - mitomycin-C 15mg/m2 20mg 2hr D2-3 + [fluorouracil 500mg/m2 645mg IP 1hr D1-5 + gentamicin 40mg IP 1hr D1-5 + sodium bicarbonate 2800mg IP 1hr D1-5]
According to available lab data since 2022-07-05 in HIS5, the patient has experienced frequent occurrences of hyponatremia, hypopotassemia, hypokalemia, and hypomagnesemia. However, during the same time frame, there have been few instances of hyper- or hypophosphatemia.
The patient began receiving FOLFOX treatment in August 2022, and the use of carboplatin in this treatment regimen can be associated with hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia.
It is recommended to continue monitoring the patient’s electrolyte levels and prescribe supplements as needed. If it becomes challenging to maintain a balance of electrolytes through supplementation, it may be necessary to consider reducing the dose of carboplatin or switching to a different regimen.
As multiple body fluid (primarily ascites) cytological studies (2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30) did not reveal evidence of malignancy, intraperitoneal chemotherapy was discontinued while systemic FOLFOX is continued.
The lab serum magnesium levels indicated a frequent deficiency of serum magnesium in this patient.
For the magnesium sulfate prescription will expire on the weekend, a lab data renewal may assist in determining whether the magnesium supplement should continue to be administered.
Body weight has decreased by almost 10 kg in the last 3 months (33.1kg 2022-10-25 <- 42.8kg 2022-07-27 gastrectomized), and a low albumin level (3.2 g/dL 2022-10-25) could indicate malnutrition. Long-term survival may be adversely affected by malnutrition after gastrectomy for gastric cancer (ref: Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival. Ann Surg Oncol. 2018;25(4):974-983. doi:10.1245/s10434-018-6342-8)
It is advisable to begin strict nutritional follow-up as soon as possible after surgery in order to prevent a sharp weight loss in the early postoperative phase when most of the dietary problems arise.
Vitamin B12 injections might be required, as well as multivitamins and minerals.
As this patient’s weight is approximately equivalent to that of a ten-year-old child, the dosage might need to be adjusted accordingly.
[diagnosis]
[past history]
[exam findings]
[consultation]
[radiotherapy]
s/p palliative RT on 2022/06/07 (RUQ tumor), 2022/07/18 (left hilum), 2022/08/05 (left hilum), 2022/10/21 (liver, SBRT), 2023/01/02 (LUL).
[immunotherapy]
Advanced uterine leiomyosarcoma (ULMS) remains an incurable disease in most cases, and despite new drug approvals, improvements in overall survival have been modest at best. Microsatellite instability and/or high tumor mutational burden are distinctly uncommon in uterine LMS, perhaps explaining the lack of activity of immunotherapy agents observed in phase II trials in LMS.
Based on the available lab data in HIS5 since 2020-09-09, the patient’s HGB level has never reached the lower limit of normal. In 2023, the patient has received her 7th blood transfusion during this hospitalization.
There is no medication reconciliation issue found in the patient.
[tube feeding]
{not completed}
{angioimmunoblastic T cell lymphoma, high grade with neck, inguinal, retroperitoneal LN metastases and generalized skin rashes, Lugano stage III, PS:0}
[lab data]
[exam findings]
[chemoimmunotherapy]
[family meeting minutes]
In the family meeting, the attending physician Dr. Gao explained the process and precautions of autoPBSCT to the patient and his family members (sister and brother-in-law). The patient expressed his willingness to fully cooperate. However, the patient has been married before and his only daughter is currently studying in the United States and is unaware of her father’s medical condition.
The patient’s family support may be insufficient before and after the scheduled transplantation. The nursing station will assist in coordinating caregiver arrangements. The attending physician reminded the patient to inform his daughter about his condition, and the patient indicated his understanding.
[diagnosis] - 2023-03-13 admission note
[past history]
Medical history: HTN, Chronic rhinosinusitis
Operation history: - glaucoma - s/p Parotidectomy, left、submandibular gland tumor excision, left - s/p Port-A insertion, L’t after L’t cephalic vein exploration
[allergy]
[family history]
Denied family history
[exam findings]
[chemoimmunotherapy]
[assessment]
[diagnosis] - 20221219 admission note
[exam findings]
[surgical operation]
[chemotherapy]
Based on the available lab data, serum Ca levels are stably lower than the normal range. If PTH secretion is insufficient to act on kidney, bone, and intestines, hypocalcemia may occur (hypoparathyroidism). No PTH lab data available. As the serum albumin concentration is also below normal, the low calcium level could also be due to a reduction in serum albumin levels.
Even when potassium supplements are taken intermittently, serum K readings remain below normal range since December 2022. An acute increase in hematopoietic cell production is associated with potassium uptake by the new cells and this may lead to hypokalemia. Administration of vitamin B12 or folic acid to treat a megaloblastic anemia or use of granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat neutropenia are the most common scenarios in which this occurs.
[diagnosis] - 2023-03-12 admission note
[edu opinion] - 2023-03-12 admission note
History - Orbital lymphoma more commonly presents in the middle-age and the elderly. - Slowly progressing, and typically painless.
Signs - Conj: the typical lesion is salmon or flesh-pink color - Orbit, eyelid: when palpable, the masses are firm. - Lacrimal gland: an “S-shaped” mass due to the lateral location of the lacrimal gland - Proptosis - Ptosis and decreased levator function may indicate superior orbital and levator muscle involvement, and motility should also be measured if the patient complains of diplopia. - Signs are more commonly unilateral
Symptoms - Many lesions are asymptomatic but depending on the location of the mass, patients can complaint of exophthalmos, pain or diplopia, as well of conjunctival, eyelid, orbital or lacrimal gland mass.
Differential diagnosis - Benign lymphoproliferative lesions - Lymphoid hyperplasia - Systemic lymphoma - Metastasis - Amelanotic melanoma - Epithelial tumors - Inflammatory and infectious lesions - Orbital pseudotumor - Cavernous hemangioma
[past history]
[allergy]
[exam findings]
(145 - 47) / 145 - M-mode (Teichholz) = 68 - Prominent concentric LV hypertrophy and mild RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA. - Dilated LV with normal LV and RV systolic function. - Aortic valve sclerosis and mild aortic root calcification; mild MR; mild PR.
[consultation]
[chemoimmunotherapy]
[assessment]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
The WBC count reached its lowest point approximately 7-10 days after the previous chemotherapy treatment in this patient, as indicated by the time relationship between the chemotherapy dates and the lab data recorded at this hospital.
Epirubicin can cause neutropenia (in 54% to 80% of patients; with grades 3/4 in 11% to 67%; nadir occurring at 10 to 14 days and recovery by day 21) and leukopenia (in 50% to 80% of patients; with grades 3/4 in 2% to 59%). ref: UpToDate
The prophylactic administration of G-CSF after chemotherapy may be considered around one week after treatment. Another option to consider is to moderately reduce the dose of epirubicin.
Cyclophosphamide use may lead to hemorrhagic cystitis, which can cause pyelitis, ureteral disease (ureteritis), and hematuria. Therefore, please closely monitor for any signs of these possible adverse reactions. Mesna can be used for the prevention of cyclophosphamide-induced hemorrhagic cystitis in cancer patients. Patients who have difficulty emptying their bladders are at a higher risk of developing bladder toxicity. If there is a clinical concern, a bladder ultrasound should be performed, and if there is a high post-void residual, the use of mesna is also appropriate for such patients.
[exam findings]
[consultation]
[chemoimmunotherapy]
diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg [assessment - appetite stimulant]
The patient reached his lowest recorded weight of 52.6kg on 2023-01-13, before slightly increasing to 54.6kg on 2023-02-24. The patient is currently receiving nutrition through a nasogastric tube and it is recommended to provide sufficient calories, protein, and other nutrients.
Previously in another pharmacist note, megestrol was recommended as an appetite stimulant, but if the patient cannot tolerate it and there is still a need for an appetite stimulant, Pilian (cyproheptadine 4mg/tab) might be also considered as an off-label alternative for decreased appetite due to chronic disease. The recommended dosage for Pilian is an initial 2mg four times per day for one week, followed by 4mg four times per day.
Quetiapine might then be considered as a last resort to increase weight, but it comes with the cost of dyslipidemia.
[assessment - pain control]
MXL (morphine 60mg/cap) 1# Q12H, fentanyl transdermal patch 50ug/h 2# Q3D, OxyNorm (oxycodone 5mg/cap) 2# Q4H have been properly prescirbed to deal with the backgroud pain.
NG tube OxyNorm administration: pour the small granules out of the OxyNorm capsules, dissolve them in drinking water, and pass them through the feeding tube.
If the patient still experiences breakthrough pain with a high VAS score, the addition of PRN morphine might be considered.
HGB 11.3 g/dL 2023-02-09 <- 6.5 g/dL 2023-02-06, in this case, anemia has been mitigated.
Platin- and taxel-based treatments have been administered to the patient.
2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. https://doi.org/10.1200/jco.20.01399
The platinum agents cisplatin and carboplatin are used both as single agents and to form the backbone for most combination regimens to treat metastatic and recurrent head and neck cancers. Although carboplatin is often considered to be less systemically effective than cisplatin in head and neck cancer, there is little direct evidence. Carboplatin may be preferred in some cases since it is associated with less neurotoxicity, nephrotoxicity, ototoxicity, and nausea and vomiting compared with cisplatin, although carboplatin causes more myelosuppression.
[duplicate note]
Since the patient has lost more than 10kg of body weight over the past 5 months (64.4kg 2022-09-17 -> 52.6kg 2023-01-13), possibly as a result of tumor-induced cachexia, it is recommended that the patient consume more and/or receive more intensive nutritional support. The addition of some appetizers, such as megestrol, might be beneficial.
Metoclopramide has been prescribed. The use of Emend (aprepitant) for antiemetic effect might be considered if nausea and/or vomiting is observed.
[exam findings]
[consultation]
[exam findings]
[consultation]
[chemotherapy]
[assessment]
The patient’s renal function has declined, as evidenced by a decrease in creatinine clearance based on Cockcroft-Gault formula to 33mL/min as of 2023-03-06.
In patients with a CrCl between 25 and 50 mL/min, a recommended dose of 1g Q12H for meropenem is advised, compared to the intended dose of 1g Q8H.
By the way, there is no dosage adjustment necessary for any degree of kidney dysfunction for micafungin use. And there are no dosage adjustments for nystatin provided in the manufacturer’s labeling for patients with kidney Impairment.
{Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.}
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
[note]
2023-03-05 lab data CRP 5.25mg/dL.
2023-03-05 sputum gram’s stain result showed:
As the staining results may suggest a possibility of contamination, it may be necessary to collect a new sample.
Moxifloxacin with an antibacterial spectrum encompassing both aerobic gram-negative and gram-positive strains, as well as anaerobic bacteria, can be used for pneumonia, community-acquired, outpatients with comorbidities and inpatients as an alternative agent. It is not recommended to be used in patients with risk factors for P. aeruginosa (ATS/IDSA [Metlay 2019]; File 2020). Based on the normal liver and kidney function lab results on 2023-03-05, the current dosage of 400 mg once daily is appropriate and does not require any adjustments.
[tube feeding]
Broen-C (bromelain + L-cysteine) is an enteric-coated tablet designed to prevent the destruction of the bromelain enzyme by gastric juice.
Bromelain is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. ref: Mala T, Anal AK. Protection and Controlled Gastrointestinal Release of Bromelain by Encapsulating in Pectin-Resistant Starch Based Hydrogel Beads. Front Bioeng Biotechnol. 2021;9:757176. Published 2021 Oct 29. doi:10.3389/fbioe.2021.757176
There are no other drugs in the inventory that contain bromelain.
[tube feeding]
[tube feeding]
[tube feeding]
[tube feeding]
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
[assessment]
Lab data
According to recent lab results, there is no longer leukopenia observed, but instead an overboosted WBC count accompanied by an elevated CRP reading (G-CSF administered on 2023-02-27). Please be aware of any signs of infection or inflammation. Anemia has gradually improved, and there is no observed thrombocytopenia.
The patient received injectable Amsulber (ampicillin + sulbactam) from 2023-02-23 to 2023-03-02 and has been taking oral Soonmelt (amoxicillin + clavulanic acid) since 2023-03-03. However, there has been no recent culture result available for the patient.
The laboratory results from 2023-02-28 also showed 4+ stool occult blood, which could be a possible cause of the anemia. It would be beneficial to rule out gastrointestinal bleeding before discharging the patient.
[exam findings]
[chemotherapy]
[assessment]
[exam findings]
[consultation]
[chemotherapy]
2023-03-01 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7
2023-02-02 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7
2021-05-17 ~ 2021-07-05 UFT (tegafur + uracil) KUFT01
[assessment]
Lab data
According to the lab data on 2023-03-01, leukopenia has improved in the patient. However, anemia is still progressing, and blood transfusion might be necessary.
Erythropoiesis-stimulating agents (ESAs) have been recommended as an effective treatment option for lower-risk MDS, including biosimilar epoetin alfa. ref: Epoetin alfa for the treatment of myelodysplastic syndrome-related anemia: A review of clinical data, clinical guidelines, and treatment protocols. Leuk Res. 2019;81:35-42. doi:10.1016/j.leukres.2019.03.006
In addition to leukopenia and anemia, the patient has been experiencing thrombocytopenia for years with no substantial improvement. Therefore, increased risk of bleeding should be carefully monitored and managed.
Thrombocytopenia is a significant problem in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Eltrombopag, a thrombopoietin receptor agonist, has shown potential clinical activity in MDS and AML clinical trials. Studies have shown that eltrombopag is well tolerated and clinically effective in both low-risk and higher-risk MDS and AML patients. ref: Eltrombopag reduces clinically relevant thrombocytopenic events in higher risk MDS and AML. Lancet Haematol. 2018;5(1):e6-e7. doi:10.1016/S2352-3026(17)30229-6
There was another study evaluated the safety and efficacy of Eltrombopag in low to intermediate risk myelodysplastic syndromes (MDS) patients. The primary efficacy endpoint was hematologic response at 16-20 weeks, and 44% of the patients responded. The safety profile was consistent with previous studies, and Eltrombopag was effective in restoring hematopoiesis in these patients. ref: Eltrombopag monotherapy can improve hematopoiesis in patients with low to intermediate risk-1 myelodysplastic syndrome. Haematologica. 2020;105(12):2785-2794. Published 2020 Dec 1. doi:10.3324/haematol.2020.249995
[present illness] - 2023-02-27 admission note
[past history]
[allergy]
[family history]
[exam findings]
[chemoimmunotherapy]
[G-CSF]
[assessment]
It is recommended avoiding the administration of filgrastim from 24 hours before to 24 hours after the administration of cytotoxic chemotherapy, due to the potential sensitivity of rapidly dividing myeloid cells to the cytotoxic effects of chemotherapy.
Filgrastim was administered on 2023-02-27 and chemotherapy is scheduled to be administered on 2023-03-01, with one day in between. Our administration pattern for the patient helps to uphold this principle without an issue.
[exam findings]
[surgical operation]
[chemoimmunotherapy]
[assessment]
A blood transfusion may be considered in light of the patient’s HGB level of 8.6 g/dL, PLT count of 31K/uL, and 4+ stool occult blood in 2023-02-28 lab results.
The sputum culture result 2023-02-28 revealed the presence of 1+ gram-positive cocci and 2+ gram-negative bacilli. Levofloxacin has been prescribed appropriately to target and treat these strains.
[present illness]
[past history] - 2023-02-25 admission note
[allergy]
[family history]
[exam findings]
[medication]
[assessment]
Based on the patient’s medication history of erlotinib followed by afatinib, it can be inferred that the disease is likely positive for EGFR exon 19 deletion or L858R, S768I, L861Q, and/or G719X mutations.
The patient had Grade 1 diarrhea which responded well to Smecta treatment (bowel movement of 3 times each day on 2023-02-27 and 2023-02-28). Additionally, the patient also experienced Grade 2 dermatitis and onychomycosis, which are currently being treated externally with tetracycline. If severe or prolonged diarrhea is not responding to antidiarrheal agents, GILOTRIF should be withheld to prevent dehydration and renal failure. In addition, GILOTRIF should be discontinued for life-threatening cutaneous reactions. Severe bullous, blistering, and exfoliating lesions occurred in 0.2% of patients. Severe and prolonged cutaneous reactions also require withholding of GILOTRIF.
After ground glass opacity was detected in bilateral lower lungs on the chest X-ray 2023-02-25, and G(+) Cocci were identified from sputum culture 2023-02-26, the afatinib treatment was temporarily suspended until the lung symptoms were relieved.
The current prescription is without any issue.
[diagnosis] - 2023-02-23 admission note
[past history] - 2022-12-08 admission note
[lab data]
[exam findings]
[surgical operation]
[chemoimmunotherapy]
The most common sequelae, or aftereffects, of axillary lymph node dissection (ALND 2022-08-11) are arm lymphedema, numbness, and limited shoulder mobility.
For patients with lymphedema (ie, International Society of Lymphology - ISL stage I, II, III), there is a recommendation to measure blood pressure in the contralateral arm, particularly in any setting in which blood pressure is being closely repeatedly or continuously monitored.
The effectiveness of these treatments in patients with established breast cancer-associated lymphedema (BCAL) is summarized below.
This (2023-02-24) morning, there was a decrease in blood pressure by 10mmHg resulting in a reading of 96/57, which should be noted. If the blood pressure continues to decrease, the administration of Concor (bisoprolol 5mg) may be suspended.
No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.
[exam findings]
[assessment]
Based on the available lab data in HIS5, the patient’s HGB level has been consistently below the lower limit of normal since May 2020. The most recent HGB level recorded on 2023-02-23 was 7.4g/dL. It is recommended to closely monitor the patient’s ability to oxygenate.
For patients with chronic kidney disease-related anemia (2023-02-07 Ferritin 731.6ng/mL), the initiation of epoetin alfa or its biosimilars is generally recommended when Hb levels fall below 10 g/L, according to the Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. Reference: KDIGO clinical practice guideline for anemia in chronic kidney disease, published in Kidney Int Suppl in 2012;2(suppl):279-335.
Please evaluate if the detected bacteriuria (2023-02-24 lab result) indicates an asymptomatic UTI or not. Asymptomatic bacteriuria is common, but most patients with asymptomatic bacteriuria have no adverse consequences and derive no benefit from antibiotic therapy. With few exceptions, nonpregnant patients should not be screened or treated for asymptomatic bacteriuria.
{not completed}
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
2023-02-23 - ramucirumab 8mg/kg 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4560mg NS 500mL 46hr (Cyramza + FOLFOX, Q2WK)
2023-02-03 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2023-01-15 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2022-12-30 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2022-12-16 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2022-06-13 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr
… … ..
2022-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
… … ..
2021-06-11 - irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 4830mg NS 500mL 46hr
There is a possible trend towards leukopenia as the patient’s WBC count has gradually decreased over time.
The patient’s HbA1c levels have slowly increased and warrant attention.
Diarrhea seems to have improved as there was no bowel movement recorded on 2023-02-23.
The medications recently prescribed for the patient are in accordance with the records in the NHI PharmaCloud System, and have been correctly prescribed as self-carried items during this hospital stay to cover his underlying conditions. No issues related to medication reconciliation have been identified.
[past history]
Medical history:
Surgical: operation for endometriosis x3, 10+ years ago (open abdominal x1 + hysteroscopic x2)
Menstrual history: G0P0, Last menstrual period:2022/8/2
Has regular Pap smear examination (most recent 2022/08/03)
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemoimmunotherapy]
[past history] - 2023-02-22 admission note
[allergy]
[family history]
[lab data]
[exam findings]
[SOAP]
[chemotherapy]
[assessment]
The use of 5-fluorouracil/mitomycin or capecitabine/mitomycin in combination with radiation for the treatment of anal cancer was considered (2023-02-10). A population-based study found that capecitabine/mitomycin and fluorouracil/mitomycin given concurrently with radiation achieved similar disease-free survival (DFS) and anal cancer-specific survival (ACSS). As such, substituting capecitabine for infusional 5-FU may be a viable option for patients and healthcare providers who prefer to avoid the potential complications and inconvenience of a central infusional device. (Reference: “A comparison between 5-fluorouracil/mitomycin and capecitabine/mitomycin in combination with radiation for anal cancer.” J Gastrointest Oncol. 2016;7(4):665-672. doi:10.21037/jgo.2016.06.04)
The mitomycin and fluorouracil with concurrent radiation (FUMIR) regimen was ultimately chosen for the patient. There are multiple variations of this regimen. The standard administration of 5-FU involves a continuous infusion over 4 days, specifically on Day 1-4 and 29-32. (ref: Mitomycin and Fluorouracil With Concurrent Radiation (FUMIR) Regimen for Anal Cancer. Hosp Pharm. 2013;48(6):464-469. doi:10.1310/hpj4806-464). Due to the patient’s advanced age, a 3-day infusion was utilized during this hospitalization, with a weekend break in between.
Lab results 2023-02-22 revealed that the CBC, WBC DC, Na, K, liver and kidney function were grossly normal, indicating no significant abnormalities.
In the review of systems section of the admission note (2023-02-22, yesterday), it was documented that the patient had been experiencing constipation for a period of two months, as well as anal bleeding with pain. The prescription of sennoside has been appropriately made. If anal bleeding persists, the addition of tranexamic acid may be considered as a potential treatment option.
A summary of the compatibility of mitomycin with various intravenous solutions is listed as following: mitomycin is not compatible with D5W, Dextrose 3.3% in sodium chloride 0.3%, and Dextrose 5% in water. Compatibility with D10W, D5LR, D5NS, 1/2NS, D5W-1/2NS and Ringer’s Injection is untested. IV compatibility with Normal saline (Sodium chloride 0.9%) is variable; Lactated Ringer’s Injection, Sodium chloride 0.4%, Sodium chloride 0.6%, and Sodium lactate 1/6 M is compatible.
This patient passed away at 10:19, 2022-11-03.
[lab data]
2023-06-26 CMV viral load assay Target not detecetedIU/mL
2023-06-19 CMV viral load assay Target not detecetedIU/mL
2023-06-12 CMV viral load assay Target not detecetedIU/mL
2023-03-14 CMV IgM Nonreactive
2023-03-14 CMV IgM Value 0.57 Index
2023-03-14 CMV_IgG Reactive
2023-03-14 CMV_IgG Value 393.8 AU/mL
2023-02-16 FLT3-D835 Undetectable
2023-02-15 BCR/abl Undetectable
2023-02-15 PML-RARA Undetectable
2023-02-13 FLT3/ITD Undetectable
2023-02-13 NPM1 Undetectable
2023-02-04 Anti-HBc Nonreactive
2023-02-04 Anti-HBc-Value 0.21 S/CO
2023-02-04 Anti-HBs 1.78 mIU/mL
2023-02-04 Anti-HCV Nonreactive
2023-02-04 Anti-HCV Value 0.09 S/CO
2023-02-04 HBsAg Nonreactive
2023-02-04 HBsAg (Value) 0.36 S/CO
2023-02-04 Anti-HBc IgM Nonreactive
2023-02-04 Anti-HBc IgM Value 0.10 S/CO
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
CYTARABINE (ARA-C) HIGH DOSE - Consolidation chemotherapy for AML in remission — https://nssg.oxford-haematology.org.uk/myeloid/protocols/ML-4-cytarabine-ara-c-3g-m2.pdf
ACUTE MYELOID LEUKAEMIA - CYTARABINE (3000mg/m2) — https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/AML/Cytarabine3000.pdf
{DLBCL}
[diagnosis] - 2022-07-31 discharge diagnosis
[lab data]
[exam findings]
[consultation]
[chemoimmunotherapy]
[exam findings]
[consultation]
[chemotherapy]
[tube feeding]
Keppra: In this hospital, there is a liquid form of Keppra oral solution (levetiracetam 100mg/mL, 300mL per bottle) that is suitable for tube feeding.
OxyNorm: Pour the small granules out of the OxyNorm (oxycodone 5mg/cap) capsules, dissolve them in drinking water, and administer them through a tube feeding.
OxyContin: OxyContin (oxycodone 10mg controlled-release tablet) is a long-acting formulation. Grinding the tablet will destroy the controlled-release design and cannot maintain long-lasting effects. Its use is not recommended for tube feeding.
[drug interaction]
Morphine (8mg IVD PRNQ6H currently) is contraindicated when used concurrently with monoamine oxidase inhibitors (MAOIs, linezolid 600mg IVD Q12H currently).
There is a possibility that monoamine oxidase inhibitors may enhance the adverse/toxic effects of morphine. Please monitor any possible adverse reactions carefully.
[diagnosis] - 2023-01-16 admission note
[past history]
[allergy]
[family history]
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[assessment]
Except for urticaria, the underlying conditions listed in the problem list are appropriately treated with corresponding medications.
As a premedication, a single shot diphenhydramine is used in the current chemotherapy regimen, however, the newer, second generation H1 antihistamines are recommended as first-line therapy for urticaria. These newer drugs are minimally sedating, are essentially free of the anticholinergic effects that can complicate use of 1st generation agents, have few significant drug-drug interactions, and require less frequent dosing compared with first-generation agents. It is recommended to initialize a 2nd generation antihistamine at standard therapeutic dose:
{not completed}
[exam findings]
2023-02-08, -02-05, -01-31 CXR
2023-02-05 CT - brain
2023-02-03 MRI - brain
2023-02-03 Electroencephalography, EEG
2023-02-03 Peripheral Vascular Test - vein, lower limbs
…
…
…
lab data
surgical operation
radiotherapy
chemoimmunotherapy
2023-01-23 urine culture found Candidas abicans 50000 colony count CFU/cc. Treatment of candidemia and invasive candidiasis in nonneutropenic patients could be an echinocandin (1. caspofungin 70 mg IV loading dose, then 50 mg IV daily; 2. micafungin 100 mg IV daily; 3. anidulafungin 200 mg IV loading dose, then 100 mg IV daily. Items 2 and 3 are not necessary to be dose adjusted for any degree of kidney impairment and they are available in this hospital.) is recommended as initial therapy. (ref: https://www.uptodate.com/contents/image?imageKey=ID%2F87676)
2023-01-13 anaerobic culture of the perineuim was found to contain Bacteroides thetaiotaomicron 3+ that was sensitive to metronidazole and ampicillin/sulbactam. It is not necessary to adjust dose for metronidazole if CrCl is greater than 10, while for ampicillin/sulbactam, CrCl is greater than 30. Keep metronidazole use is recommended.
If Keppra (500mg Q12H) is not demonstrated to be effective for seizure control, valproate (no dosage adjustment necessary if CrCl >= 10 mL/min) or carbamazepine (no dosage adjustment necessary for kidney impairment) might be added.
[compatible solutions to mitigate hypernatremia that do not rely on saline]
Following is a list of the selected injectable medications in the active prescription and their compatibility with non-saline-based solutions according to MicroMedex.
Use potassium supplements if necessary
WBC returned to 5.05K/uL on 2023-02-12, neutropenia not observed.
[diagnosis] - 2022-12-02 admission note
[past history]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[exam findings]
[chemotherapy]
[assessment]
[diagnosis] - 20230203 admission note
[past history]
[allergy]
[exam findings]
[consultation]
[chemotherapy]
[medication]
{not completed}
[exam findings]
[diagnosis] - 2023-01-12 discharge note
[Past History]
[Family History]
[lab data]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]
[assessment]
[potential drug interactions]
Flunarizine (patient-carried) is cocommitant with clonazepam, diphenhydramine, estazolam and fexofenadine currently.
According to the flunarizine product monograph (https://www.aapharma.ca/downloads/en/PIL/2021/Flunarizine_PM_EN.pdf), use of CNS depressants, including alcohol, should be avoided during treatment with flunarizine due to the risk of excessive sedation.
There is also an antivertigo preparation available in stock known as Nilasen (betahistine 24mg/tab), which has a lower risk of drug interaction than flunarizine and can be considered as a 1# daily dosage alternative.
There is no specific pharmacist shift handover to follow in this patient.
[drug identification]
[diagnosis] - 2023-02-01 discharge note
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[diagnosis] - 2023-02-01 discharge note
[lab data]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]
[diagnosis] - 2022-10-01 discharge
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
Esophageal and Esophagogastric Junction Cancers, NCCN Evidence Blocks, 2022-09-07, Version 4.2022, ESOPH-F 5 OF 17, p49 = Principles of Systemic Therapy > Regimens and Dosing Schedules > Other Recommended Regimens
Administration
[assessment]
In response to anemia (2023-01-27 HGB 7.5g/dL), LPRBC 2U was transfused on 2023-01-28 to treat the condition.
Cold hemagglutination was observed in 2023-01-27 lab data.
[exam findings]
[assessment]
Despite having a pacemaker implanted, the patient’s heart rate doubled from 64 (2023-01-29 20:03) to 144 (2023-01-30 08:50).
Runaway pacemaker occurs when the pacemaker’s pulse generator discharges at a rate above its preset upper limit. The malfunction lies entirely within the pulse generator. It should be suspected if pacemaker dysrhythmias occur at rates greater than 130 beats/min or the upper rate limit if this is known. ref: Tachycardia in the presence of a pacemaker. Postgrad Med J. 2004;80(940):119-122. doi:10.1136/pmj.2002.004036q
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
When pulmonary symptoms limit the patient’s ventilation, oxygenation becomes more important.
Laboratory 2023-01-28: MCV 68.5fL, MCH 21.5pg, both below LLN since 2nd half 2022, there may be an iron deficiency. It is recommended that the patient’s body iron level be checked in order to determine whether iron supplements need to be added.
[tube feeding, drug interactions]
Scrat (sucralfate) should be administered on an empty stomach. Please shake suspension well before use and do not administer antacids within 30 minutes of administration of sucralfate. In general, it is recommended to separate administration of other oral medications and sucralfate by at least 2 hours. With Panzolec (pantoprazole) 40mg IVD QD (09:00) and Scrat 1g PO Q6H (05:00, 11:00, 17:00, 23:00), it should be less likely that there will be obvious interactions between the two. The adjustment does not need to be made.
Bromelain, the main active ingredient in Broen-C tablets, is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. The drug is therefore designed to be enteric coated. There is no alternative for this ingredient available in the hospital at present time.
Management of vasogenic edema in patients with primary and metastatic brain tumors - glucocorticoids - ref: https://www.uptodate.com/contents/management-of-vasogenic-edema-in-patients-with-primary-and-metastatic-brain-tumors
2023-01-11 brain MRI showed increased heterogeneous soft tissue enhacement in the right temporal lobe and right cavernous sinus with right cavernous ICA encasement. suspected radiation necrosis or tumors.
Systemic glucocorticoids are the mainstay of symptomatic therapy for peritumoral edema. They play a role in stabilizing patients awaiting definitive treatment of the tumor as well as in palliative management of edema related to treatment-refractory tumors.
Emergency management of increased ICP
Initiation of glucocorticoids
Dexamethasone dose and schedule
Response assessment
Inadequate response to initial dose
Approach to taper
Refractory edema
Symptomatic plateau waves
{drug interactions}
[exam findings]
[tube feeding]
Harnalidge (tamsulosin, designed for extended release) 0.4mg PO QDAC should be replaced by Urief (silodosin) 8mg PO QD for tube feeding.
Concor (bisoprolol 5mg/tab) package insert recommends swallowing the medication with some liquid and not chewing it. For tube feeding, the simple suspension method (SSM) involves suspending tablets and capsules in warm water for decay and suspension prior to administration, which can be applied to the Concor tablets.
{High grade B-cell lymphoma with left aspect of mandible, multiple lymph nodes in the abdomen and the regions about the pericardium and pleura of left lower lung field, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1}
In late October 2022 and mid-Jan 2023, grade 4 neutropenia occurred approximately between 1-2 weeks after the patient’s receiving R-CHOP. As soon as neutropenia is identified, filgrastim and/or lenogastin has been appropriatedly administered. The WBC count returned to 1440 cells/uL on 2023-01-16.
Following a peak of 220mg/dL (2023-01-14 17:00), the patient’s serum glucose level returned to 114mg/dL (2023-01-16 05:17). It is not necessary to modify the patient’s antihyperglycemic agent immediately.
To treat neutropenic fever in this patient with hematologic malignancy, it is recommended to initialize an antipseudomonal beta-lactam agent, such as cefepime, meropenem, imipenem, or piperacillin-tazobactam. Since 2023-01-13, cefepime 2000mg IVD Q8H has been used.
Since the culture result has not been released, teicoplanin 600 mg IVD QD and fluconazole 300 mg PO QD have also been added in order to broaden the scope of coverage.
Based on 2023-01-13, 15, 16 lab data, there is no evidence that the patient’s liver or kidney function has declined. Therefore, no dose adjustment is required for the medication prescribed.
Cimetidine may increase the serum concentration of metformin. The AUC of metformin increased 40% when combined with a single dose of cimetidine (400 mg) and increased 50% after treatment with cimetidine (400 mg twice daily) for 5 days in healthy volunteers. In an another study of 15 healthy volunteers, cimetidine administration decreased metformin renal tubular clearance by 18.7% to 48.2%, depending on the individual’s organic cation transporter 2 (OCT2) genotype. Participants carrying the OCT2 808G>T polymorphism had lower baseline tubular clearance of metformin and a correspondingly lower magnitude of interaction with cimetidine.
As the patient’s renal function still works (2023-01-05 Cre 1.08mg/dL, eGFR 53, BUN 14mg/dL), it is less likely to develop lactic acidosis, however, close monitoring might be necessary.
The historical time series lab data suggest that the roughly cyclic trough WBC level (neutropenia events) was frequently observed around 3 weeks following each R-CHOP treatment. It might be necessary to plan in advance for the possible neutropenia 3 weeks after this hospital stay in order to ensure the G-CSF is accessible to the patient during the Chinese New Year long holidays.
Diagnosed T2DM. Glucose One Touch data: 228 (2022-08-31 17:05), 203 (2022-09-01 06:09), 256 (2022-09-01 11:12). No HbA1c records found.
This patient is taking self-carried gliclazide 15mg QD and metformin 500mg TIDCC.
Suggestion:
{poorly differentiated squamous cell carcinoma of esophagu, cT3N2M0 stage III; poorly differentiated adenocarcinoma of stomach with liver metastases, cT3N0M1, stage IV}
Anemia can be classified based on whether the MCV is low, normal, or elevated. A decreased MCV (usually less than 80 fL) indicates a defect in the synthesis of hemoglobin, which may be caused by an iron deficiency. And the presence of an increased MCV (>100 fL) is often attributed to asynchronous maturation of nuclear chromatin, although other factors may also contribute.
A low MCH is typically reflected in an enlarged area of central pallor in RBCs on the peripheral blood smear, which defines “hypochromia” on the blood smear. This may be seen in iron deficiency and thalassemia.
Very low MCHC values are typical of iron deficiency anemia, and very high MCHC values typically reflect spherocytosis or RBC agglutination.
[assessment]
[assessment]
[tube feeding]
Current administration routes are IVD and TPN; there is no tube feeding at this time.
{not completed}
[duplicate note]
[assessment]
As of 2023-01-10, WBC is 2.87K/uL, neutrophil is 53%, and ANC is greater than 1500 cells/uL.
However, there is a trend downward in WBC count which should be noted.
{Recurrent left breast cancer with bilateral lung, right pleura, liver, bone and lymph node metastases, rcTxN2M1, stage IV}
[note]
{colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB}
[tube feeding]
[OxyNorm tube feeding]
[no sodium version of piperacillin + tazobactam]
[tube feeding]
It is possible to peel the Concor (bisoprolol 1.25mg) tablet in half or grind it for tube feeding.
[assessment]
A higher overshoot of bilirubin total than bilirubin direct might hint a sign that the patient’s red blood cells are breaking down at an unusual high rate.
During the first half hour of 14 o’clock 2023-01-04, there was a brief tachycardia moment with SBP exceeding 200mmHg. The vital signs are relatively stable now.
According to the Concor (bisoprolol 5mg/tab) package insert, the drug shold be swallowed with some liquid and not to be chewed. We are in the process of consulting the distributor for a response.
Atenolol can be used as an alternative antihypertensive agent (atenolol 50mg ~ bisoprolol 5mg) available under the brand name Urosin in the stock.
diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg diphenhydramine 30mg + granisetron 1mg[assessment]
[assessment]
{drug identification}
The drug imprinted “CTP A23” on the red-white capsule has not been found in available databases and remains unidentified.
[ABX use evaluation]
For most adults, the initial recommended antifungal treatment is an echinocandin (caspofungin, micafungin, or anidulafungin) given through the vein. Fluconazole, amphotericin B, and other antifungal medications may also be appropriate in certain situations.
[note]
[assessment]
During the past month, the patient’s liver and kidney functions have declined.
As the patient’s CrCl level is 17 mL/min according to the Cockcroft-Gault formula, it is recommended that the dosage of clarithromycin and amoxicillin be halved.
For patients with severely impaired kidney function, neither cisplatin nor carboplatin is recommended. Cetuximab is being administered as part of the patient’s treatment with CCRT.
In this patient, transthoracic echocardiography (2022-11-22) revealed dilated atria and RV, grade 1 LV diastolic dysfunction, mild AR, MR, and PR, moderate to severe TR, and pulmonary hypertension. Cardiopulmonary arrest or sudden death occurred in patients with squamous cell carcinoma of the head and neck receiving cetuximab with radiation therapy or a cetuximab product with platinum-based therapy and fluorouracil. It is recommended to closely monitor serum electrolytes, including magnesium, potassium, and calcium, during and after cetuximab administration.
{not completed}
{not completed}
[assessment]
{drug identification}
A request has been made for us to identify drugs for 10 items.
In total, 9 items have been identified as follows, with 1 item remaining unidentified.
These drugs will be sent back to ward by the in-hospital porter.
{not completed}
[assessment]
{Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2(-), stage IIA s/p MRM on 2022-05-13}
[note]
[assessment]
{NSCLC, not completed}
[note]
this patient EGFR L858R mutation detected, ROS1 (IHC 1+, FISH undetected)
NCCN v5.2022
lab data
exam findings
consultation
radiotherapy
chemoimmunotherapy
The disease is characterized by L858R(+), exon19del(-), ALK(-), and PD-L1<1%. This patient has been treated with oral afatinib(2021-12 ~ 2022-07)/dacomitinib(2022-08 ~ undergoing) and IV ramu(2021-12 ~)/nivo(2022-01 ~)/ipi(2022-03 ~). It appears that the current regimen is still effective to keep the disease stable (2022-02 and 2022-06 CT: regression; 2022-09 CT: stationary).
The serum potassium level in 2022-10-17 was 2.9 mmol/L, and it might be beneficial to add potassium supplements.
The main concern for the patient and his caregiver might be pain management. For patients who require four or more doses of short-acting opioids consistently each day, addition of a long-acting opioid should be considered based on the total daily dose. A controlled-release oxycondone regimen has been prescribed to the patient since 2022-10-18.
In the event that the patient’s goals are not met (uncontrolled pain persists), then administer an opioid dose equivalent to 10%~20% of the total opioid taken in the previous 24 hours and reassess effectiveness and adverse effects (at 15 minutes if administered IV or at 60 minutes if administered PO).
[assessment]
{Left ovarian cancer (clear cell carcinoma) post Debulking surgery on 2022/06/08, pT2aN0M0, FIGO stage IIA}
2022-12-03 CXR
2022-11-21, -11-17 CXR
2022-11-18 SONO - chest
2022-11-13 ECG
2022-10-20 CT - abdomen
2022-10-14 CXR
2022-07-29 Whole body PET scan
2022-07-28 CT - chest
2022-06-06 Patho - lymphnode biopsy
2022-06-06 CT - abdomen
2022-05-31 2D transthoracic echocardiography
2022-05-23 Patho - lymphnode biopsy
2022-05-23 Patho - breast biopsy (no need margin)
2022-05-17 SONO - breast
2022-03-09 CT - abdomen
2021-12-09 Whole body PET scan
2021-11-26 CT - abdomen
2021-11-18 SONO - abdomen
2021-08-27 CT - abdomen
2021-07-08 Gynecologic ultrasonography
2021-06-10 CT - abdomen
2021-05-27 SONO - abdomen
2021-03-10 CT - abdomen
2020-12-01 Patho - soft tissue tumor, extensive resection
2020-11-30 Patho - ovary (tumor)
2020-11-18 Whole body PET scan
2020-11-18 Gynecologic ultrasonography
2020-11-16 CT - abdomen
2020-10-28, -09-16, -09-15, -08-26, -08-25, -08-13 Body fluid cytology - ascites
2020-08-13 Patho - peritoneum biopsy
2020-08-07 Patho - ovary biopsy/wedge resection
2020-08-06 Gynecologic ultrasonography
2020-08-05 CT - abdomen
2020-08-05 SONO - abdomen
2020-05-16 Mammography
consultation
chemoimmunotherapy
{Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1}
[drug identification]
Total 1 drug for identification.
The identified item is Vemlidy film-coated tablet containing tenofovir alafenamide 25mg which is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults with compensated liver disease.
The drug will be sent back to ward by the in-hospital porter.
{pancreatic cancer, endometrial cancer}
It should be noted that both serum creatinine and BUN increased 50% in the last two weeks (Cre 1.76 mg/dL 2022-11-30 <- 1.18 mg/dL 2022-11-16; BUN 33 mg/dL 2022-11-30 <- 20 mg/dL 2022-11-16), as well as bilirubin total exceeded 6 x ULN (6.95 mg/dL 2022-11-30).
2022-11-30 eGFR 31.2
2022-11-30 bilirubin total 6.95 mg/dL, ALT 442 U/L, AST 342 U/L
It is suggested to ensure that the patient’s kidney and liver function are in good condition prior to the chemotherapy.
[note]
[assessment]
{This 80-year-old man patient is a case of Diffuse large B-cell lymphoma, Non-GCB type, at the right maxillary gingiva and tuberosity, Ki-67 index >95%, Lugano stage II, IPI score: 1, Low risk group, PS:0}
[assessment]
{Esophageal cancer, cT2N2Mo stage III, Port-A insertion at left cephalic vein on 20220922, jejunostomy tube insertion at abdomen on 20220922}
[assessment]
{Protocol: Capsule suspension preparation and NG tube dispensing procedures for Xtandi (enzalutamide, 160mg dose)}
The following in-situ oral dosing syringe suspension preparation and NG tube dispensing procedures were identified as being facile and which essentially eliminate human exposure to capsule components:
Utensils: Tweezers, medical grade scissors, 2-3mL oral dosing syringe, 20mL oral dosing syringe, NG tube, and one 2-3 oz (60-90 mL) glass or plastic dosing container (e.g., beaker or med cup).
Materials: Ethanol, 95%, Deionized water, 4x40mg enzalutamide capsules
Please prepare two vials of 99.5% alcohol (drug code ‘CALCO01’), add one ml of purified water, take eight ml of the solution to dissolve one split capsule of 40 mg Xtandi, and tube feed this solution containing enzalutamide with prandial.
{Mesenchymal chondrosarcoma, high grade}
{expired}
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
Following standard brain RT and TMZ for multiple glioblastomas, the NCCN evidence blocks (2022-09-29 version 2.2002) recommends clinical trials, surgery for symptoms of large lesion, alternating electric field therapy, and palliative/best supportive care.
It has been reported in a review article that studies have been conducted using intra-arterial delivery of chemotherapeutics for the treatment of GBM, which may be considered as an optional last resort. (ref: A systematic review on intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme: The state-of-the-art. Front Oncol. 2022;12:950167. Published 2022 Sep 23. doi:10.3389/fonc.2022.950167 )
In addition, there is also an article reported CAR T cell therapy and its potential to be integrated into the therapeutic paradigm for aggressive gliomas in the future. (ref: Clinical utility of CAR T cell therapy in brain tumors: Lessons learned from the past, current evidence and the future stakes [published online ahead of print, 2022 Oct 3]. Int Rev Immunol. 2022;1-19. doi:10.1080/08830185.2022.2125963 )
[assessment]
[assessment]
{drug identification}
requesting drug identification for 4 items.
the 3 items are identified as following while the other 1 item remains unknown.
The drug will be sent back to ward by the in-hospital porter.
{drug identification}
It was requested that four drugs be identified.
The items identified are as follows:
These drugs will be sent back to ward by an in-hospital porter.
[assessment]
{drug identification}
requesting drug identification for 6 items.
the 5 items are identified as following while the other 1 item remains unknown.
Indershin (indomethacin 25mg) Anrokin (chlorzoxazone 200mg) Leflo (levofloxacin 500mg) Ketofen (ketoprofen 50mg) Decan (dexamethasone 0.75mg)
The drugs were packaged as one dose in an opaque bag, which was opened irreversibly. The checked drugs will not be returned to the ward due to the possibility of contamination.
[assessment, not posted]
[assessment]
{gastric signet-ring cell carcinoma}
[assessment]
[assessment]
[assessment]
The trough value of vancomycin was reported on 2022-11-10 at 25.4 mcg/mL.
A blood draw time of “2022-11-10 00:00” has been recorded, this should be due to an invalid entry, please confirm that the concentration is actually a “trough”.
Redraw the value if it is not truly a “trough”.
In the event that the value is a real “trough”, then it is recommended to hold vancomycin and perform a renal function test.
[assessment]
[assessment]
{drug identification}
requesting drug identification for 1 item.
the item is identified as Serenal (oxazolam 10mg/cap).
the drug will be sent back to ward by an in-hospital porter.
[note]
{colon cancer}
[assessment]
{Extranodal NK/T-cell lymphoma, nasal type, Lugano stage II, PS: 0}
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[note]
[assessment]
[assessment]
{breast cancer with brain mets}
This patient had received doxorubicin/cyclophosphamide (6, 2022-02-24 ~ 2022-06-07) and docetaxel (5, 2022-06-30 ~ 2022-09-01)
Brain MRI (2022-08-10) showed one solid mets increased in size and brain CT (2022-09-09) showed mild dilated intraventricular and extraventricular CSF spaces and two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe.
Pathology (2022-01-13) comfirmed breast cancer brain mets triple negative. Neither trastuzumab and its biosimilars/ADC(antibody drug conjugates) nor CDK4/6 inhibitors (e.g., ribociclib, palbociclib) might likely to show effective.
National Health Insurance covers PARP (poly ADP-ribose polymerase) inhibitors like olaparib and talazoparib for metastatic triple negative breast cancer with BRCA1/2 mutations since 2022-08-01.
For patients with triple-negative brain metastases from breast cancer (BCBM), two chemotherapy regimens seem to show specific CNS activity:
{ovarian cancer s/p debulking surgery}
[assessment]
2022-08
{DLBCL, diffuse large B-cell lymphoma}
[drug identification]
One drug for identification.
The drug will be sent back to ward by the in-hospital porter.
[drug identification]
Two drugs need identification.
the 2 identified items has been shown as following:
these drugs will be sent back to ward by an in-hospital porter.
{Endometrioid carcinoma, grade 2, of the uterine endometrium, AJCC Pathologic stage — pT3aN1aM1, stage IVB / FIGO stage IVB, s/p Laparoscopic gynecologic oncology staging surgery.}
lab data
exam findings
consultation
SOP
radiotherapy
chemoimmunotherapy
[assessment]
{Gastric adenocarcinoma of antrum with gastric outlet obstruction cT3N3bM1, stage IV, ECOG 1 status post laparoscoppic gastrojejunostomy and Port-A implantation on 2022-06-16}
[exam findings]
[chemoimmunotherapy]
2023-05-30 - etoposide 500mg/m2 1000mg NS 50mL 2hr D1-4
2022-06-02 - undergoing - Imbruvica (ibrutinib) 140mg/cap 4# QD
2022-04-11 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2022-03-11 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP)
2022-02-08 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2022-01-04 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5
2021-12-08 - cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2021-12-07 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2021-11-16 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5
2021-10-19 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 30mg BID PO D1-5
This mantle cell lymphoma patient had been treated with R-CVP/R-CHOP/R-DHAP (until April 2022) and started receiving Bruton’s tyrosine kinase inhibitor ibrutinib in early June 2022 and achieved a partial response (2022-08-19 CT). As part of this hospitalization, images will be updated.
The combination of ibrutinib and venetoclax (this is not covered by National Health Insurance at present) has been shown to promote responses in patients with relapsed or refractory mentle cell lymphoma.
[assessment]
The patient has been diagnosed with ER(+) PR(+) HER2(-) breast cancer and has been treated with letrozole, an aromatase inhibitor, in combination with the CKD4/6 inhibitor, ribociclib (2021-09-22 ~ 2022-05-25).
She was also diagnosed with EGFR Exon19 deletion, PD-L1 TPS >= 50% lung adenocarcinoma, and is currently undergoing the TKI gefitinib (2021-09-23 ~ undergoing).
The use of atezolizumab might be an option for her subsequent treatment, as her lung cancer is also characterized by PD-L1 TPS >= 50%. (2021-09-23 S2021-11626)
Her bone mets were treated with zoltedronic acid (2022-01-12, 2022-02-09) and two falling accidents were noted in July 2022. In the event that zoltedronic acid is not well tolerated by the patient, Xgeva (denosumab 120mg SC) or romosozumab (currently not available at this hospital) might be an alternative.
[assessment]
Mosarla RC, Vaduganathan M, Qamar A, Moslehi J, Piazza G, Giugliano RP. Anticoagulation Strategies in Patients With Cancer: JACC Review Topic of the Week. J Am Coll Cardiol. 2019;73(11):1336-1349. doi:10.1016/j.jacc.2019.01.017
Johnstone C, Rich SE. Bleeding in cancer patients and its treatment: a review. Ann Palliat Med. 2018;7(2):265-273. doi:10.21037/apm.2017.11.01
There has been an observation of vaginal bleeding possibly caused by bevacizumab. A transfusion might be necessary if there is a significant loss of blood (which is not the case for this patient HGB 11.0 g/dL 2022-10-06).
Tranexamic acid has not been studied in advanced cancer, but it reduces mortality due to bleeding by approximately one-third. A reduction of approximately one-third in blood loss and transfusion requirements has been seen in meta analyses of its use in elective surgery as well.
No dose-response has been seen for tranexamic acid’s therapeutic effect, and the recommended dose is 10 mg/kg per dose given intravenously every 6-8 hours, with no benefit to doses above 1 gram.
Pancreatic cancer, adenocarcinoma, pT2N2M1, stage IV with liver mets with Paclitaxel and Gemcitabine Gastric cancer, adenocarcinoma, pT2N3aM0, stage IIIa Malignant neoplasm of unspecified site of left female breast
[assessment]
{HCC with lung & bone metastasis, suspected a large tumor at L5 vertebral body, R paravertebral / R perivertebral spaces}
[drug interaction]
Combination use of H2 antagonist (Famotidine) and PPI (Rabeprazole) might enhance gastric acid suppression, might also increase the potential risk of Clostridioides difficile infection. Ref:
{colon cancer}
[objective]
[not posted?]
2022-07-29 Whole body PET scan showed the FDG avid lesions in the T1 spine, in some right paratracheal and bilateral pulmonary hilar lymph nodes, in diffuse small focal areas in bilateral lung fields and in bilateral adrenal glands are either new or more evident.
In recent months, CEA lab data showed an increasing trend
F/S blood sugar level were 200 +- 20 mg/dL, body weight loss: 57kg <- 66kg (2022-06), empagliflozin 25mg QDPC or canagliflozin 100mg QDAC might be an optional add-on.
[visiting the patient]
[colon cancer]
[type 2 DM]
[dyslipidemia]
[assessment]
[felt fatigue in prior chemo]
visiting the patient at 09:47 on 2021-03-15, he is wide awake, this patient has not been administrated chemo regimen yet since this admission, in prior to the chemo course, consultations for C7 spinal segment and ONJ are arranged (based on his PET scan outcome).
he says he felt fatigue after chemo been started 2-3 days in the prior course.
HbA1c 8.3% and serum glucose (AC) 191mg/dL reported on 2021-01-14, no newer data available, could be followed up if necessary.
lab data
exam finding
consultation
(C5) Deltoid/Biceps 5 4 (C6) Wrist extensor 5 4 (C7) Triceps 5 4 (C8) Flex. dig. profundus 5 5 (T1) Hand intrinsics 5 5 (L2) Iliopsoas 0 0 (L3) Quadriceps 0 0 (L4) Tibialis ant. 0 0 (L5) Ext. hallu. longus 0 0 (S1) Gastrocnemus 0 0chemoimmunotherapy
Tagrisso - osimertinib 80mg/tab 1# QD PO
Cyramza - ramucirumab (NSCLC recommended dose in package insert: in combination with erlotinib, 10mg/kg Q2W IVD 60min)
Giotrif - afatinib 30mg/tab 1# QDAC PO
[assessment]
[drug identification]
requesting drug identification for 3 items.
the 2 items are identified as following while the other 1 item remains unknown.
these drugs will be sent back to ward by an in-hospital porter.
[drug identification]
Total 3 drugs for identification.
The 2 identified items has been shown as following while the other 1 items still remain unknown:
These drugs will be sent back to ward by the in-hospital porter.
s mouth was suctioned and a 4*8 gauze was placed at the patients
throat to prevent fluid from entering patient’s airway.[note]
Locally advanced squamous cell carcinoma of the head and neck ( https://www.uptodate.com/contents/locally-advanced-squamous-cell-carcinoma-of-the-head-and-neck-approaches-combining-chemotherapy-and-radiation-therapy )
[assessment]
chemotherapy induced oral ulcer is treated with Nincort Oral Gel (triamcinolone) and hepatitis B is surpressed using Baraclude (entecavir)
{Adenocarcinoma of splenic flexure colon with obstruction, and liver, lung, bone metastasis with carcinomatosis, cT3N2bM1c, stage IVC status post colostomy on 2021-10-06}
{vancomycin trough concentration}
There was a trough concentration of 9.4 mg/L recorded on 2022-10-03 in this patient treated with U-Vanco (vancomycin) 1000mg QW15 (based on his renal function) since 2022-09-25.
It appeared to be effective (CRP 15.84mg/dL 2022-10-03 <= 29.58mg/dL 2022-09-22) when vancomycin was used, however, it is recommended that serum vancomycin trough concentrations should always be kept above 10 mg/L to avoid resistance development. For a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L to generate the target AUC (Area under the curve): MIC of 400. (ref: Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society Of Infectious Diseases Pharmacists. Clin Biochem Rev. 2010;31(1):21-24.)
Changing the current administration frequency from QW15 to QW135 is recommended to increase the concentration to at least 10 mg/L. Thank you!
BH 172, BW 109.2, BMI 36.9
past history
family history
lab data
exam finding
consultation
multiteam
surgical operation
radiotherapy
chemoimmunotherapy
{Primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection) on 20210111.}
[objective]
[assessment]
[assessment]
The blood pressure and blood sugar levels are within the normal range.
Human albumin 20g QD, furosemide 20mg QD, and spironolactone 25mg BID are currently being used to control patient edema.
Blood pressure and blood sugar are grossly in normal range.
Human albumin 20g QD, furosemide 20mg QD, spironolactone 25mg BID are currently applied to cope with the patients edema.
[assessment]
{multiple myeloma}
[assessment]
{adenocarcinoma of rectosigmoid, not completed}
[subjective]
[objective]
In the last three months, both AST and ALT have increased.
Oxaliplatin has been associated with hepatotoxicity, including elevated transaminases and alkaline phosphatases. Peliosis, nodular regenerative hyperplasia or sinusoidal abnormalities, perisinusoidal fibrosis, and veno-occlusive lesions have been detected on liver biopsy. Patients with portal hypertension or increased liver function tests, which cannot be attributed to liver metastases, should be evaluated for hepatic vascular disorders.
Hyperuricemia is noted (serum uric acid readings have been around 9mg/dL in 2022), allopurinol or febuxostat might be indicated.
Febuxostat differs from allopurinol in a number of ways:
Feburic (febuxostat 80mg/tab) 0.5# QD is recommended.
In the last half year, serum creatinine readings have been around 2 mg/dL, indicating altered kidney function. (170cm, 78kg -> eGFR 40mL/min/1.73m2, CrCl 40~45mL/min)
Fluconazole for candidiasis, prophylaxis - Hematologic malignancy patients or hematopoietic cell transplant (HCT) recipients who do not warrant mold-active prophylaxis: Oral 400 mg once daily. If the CrCl value is less than 50 mL/minute, the dosage is recommended to be reduced by 50%. The current dose is 300mg per day, which is less than 400mg, so no urgent adjustment is necessary.
As phenytoin is an inducer of CYP3A4 and P-glycoprotein and apxaban is metabolized predominantly by CYP3A4 and a P-gp substrate, the former may decrease the serum concentration of the latter.
Another direct oral anticoagulant Lixiana (edoxaban) undergoes minimal CYP metabolism (still an p-gp substrate) might be an alternative to Eliquis (apixaban). Edoxaban can be administered 30mg once daily for patients with CrCl 15 to 50 mL/minute.
As dexlansoprazole’s pharmacokinetics are not expected to be altered in patients with renal impairment, dose adjustment is not likely to be necessary.
[assessment]
Losartan might be held temperately due to a drop in blood pressure (2022-09-20 09:21 96/56mmHg).
Blood glucose levels were elevated (2022-09-20 06:40 236 mg/dL). If the reading remains high over the next two days, then antiglycemic interventions might be necessary.
[Chief Complaint] for chemotherapy
[Present Illness] This 46-year-old female patient had invasive carcinoma of no special type with focal micropapillay pattern of the right breast cancer, pT2N1M0, stage IIB, ER (postive, +++95%), RP (postive, +++80%), Her-2/Neu(equivocal, 2+), s/p MRM and ALND on 2017/11/30, post chemotherapy with AC 4 times since 106/12-107/03/13. Adjuvant chemotherapy with Taxotere on 108/04/04-6/6 and radiotheratpy.
On 2020/12/01, microinvasive carcinoma of the left breast, AJCC 8 th edition, Pathology stage: pT1miN0; Anatomic stage IA; Prognostic stage IA if cM0. Margins: Negative, Closest margin (7 mm from deep margin). ER (Ab): Positive (60%, moderate intensity), PR (Ab): Negative, HER-2/Neu (Ab): Positive (score= 3+), s/p left partial mastectomy and sentinel lymph node biopsy, radiotherapy (Radiotherapy with 5000cGy/25 ractions of the left breast, and 6000cGy/30 fractions of the left breast tumor bed (scar) area), and status during endocrine therapy.
Followed CT on 2022/1/28 which revealed Four Metastases on both hepatic lobes are highly suspected. Her-2 overexpressed liver metastases were confirmed after liver biopsy. Bone scan revealed a hot spot in the left humeral head, some faint hot spots in bilateral rib cage, upper T-spine, L2-3 spines, lower L-spine, sacrum, bilateral sternoclavicular junctions, upper portion of the sternum, shoulders, and knees in whole-body survey.
Then she recevied C1 Herceptin, Perjenta (840mg) for loading dose on 2022/2/14, Taxotere on 2022/2/15. C2 Herceptin, Perjenta on 2022/3/7 Taxotere on 2022/3/8. C3 Herceptin, Perjenta on 2022/3/28 Taxotere on 2022/3/29. C4 Herceptin and Perjenta on 2022/4/18,Taxotere on 2022/4/19. Followed CT of chest was performed on 5/2 revealed almost resolution of metastatic hepatic tumors (with a small residual lesion in S6) compared with abdominal CT on 1/28.minimal nonspecific RML inflammation and subtle small nodules inlower lobes of lungs, susggest f/u. Chemotherapy with C5 Herceptin + Perjenta (420mg) on 2022/5/9.Taxotere on 2022/5/10. C6 Herceptin + Perjenta (420mg) on 2022/5/30.Taxotere on 2022/5/31 C7 Herceptin + Perjenta (420mg) on 2022/6/20.Taxotere on 2022/6/21 C8 Herceptin + Perjenta (420mg) on 2022/7/11.Taxotere on 2022/7/12.
Followed up CT of chest on 2022/8/8 revealed 1.almost resolution of metastatic hepatic tumors (with a small residual low lesion in S6) compared with CT on 5/4 and 2.two small nodules in Rt lung still visualized, susggest f/u.
C9Herceptin + Perjenta (420mg) on 2022/8/29 and Taxotere on 2022/8/30
This time, she was admitted for chemotherapy on 2022/9/18.
{Olfactory Neuroblastoma}
[note]
[Angiotensin-Converting Enzyme Inhibitors / Angiotensin II Receptor Blockers]
[drug identification]
[not completed]
[assessment]
[tube feeding]
The capsule of Nexium (esomeprazole 40mg/tab) should be opened and the small granules poured into drinking water before tube feeding can begin.
[objective]
CEA lab data
According to CT scan impressions, the disease had responded to the current treatment (bevacizumab + FOLFIRI) introduced in early March 2021 and remains stable in the recent half year. However, CEA readings have also increased over the past 12 months.
Upon confirmation that the disease has acquired resistance, regorafenib might be considered as a subsequent treatment option.
The underlying condition HTN appears to be well controlled during this hospitalization. There are no updated hyperlipidemia lab results available for the past two years that could be ordered if clinically indicated.
[Rectal Cancer]
initial presentation
definite diagnosis
disease extent
treatment
effect and side effect
ongoing problem
Objective:
Assessment:
Suggestion:
Objective:
Assessment:
Suggestion:
Objective:
Assessment:
Suggestion:
[assessment]
Serum uric acid lab data
There is a history of gout in this patient, and his serum uric acid level is elevated. One option might be to prescribe Feburic (febuxostat 80mg) 0.5# QD for at least seven days.
Lab data: serum creatinine (2022-09-13 2.14 mg/dL <- 2022-09-01 1.20 mg/dL), BUN (2022-09-13 39 mg/dL <- 2022-09-01 23 mg/dL). The patient’s renal function is declining.
Male, age 58, 160cm, 45kg => BMI 17.6kg/m2, CrCl 24mL/min, eGFR 32~38mL/min/1.73m2
As this patient is mildly thin, an increase in intake is recommended in order to prevent malnutrition and build up some reserve for future treatment.
The use of carboplatin has been associated with renal adverse reactions, including decreased creatinine clearance (27%), and increased blood urea nitrogen (14% to 22%). In the next chemotherapy cycle, it might be an option to reduce the dose.
{not completed}
[assessment]
The patient’s blood pressure has been around 190(+-10)/90(+-10), despite taking the following antihypertensive agents as part of the active prescription:
Clonidine can be used for chronic hypertension as an alternative agent. It is not recommended for initial management but may be considered as additional therapy for resistant hypertension in patients who do not respond adequately to combination therapy with preferred agents (ACC/AHA [Whelton 2018]). We have in stock Catapres (clonidine 0.075mg) currently. Oral form immediate release: Initial 0.1 mg twice daily; increase dose in increments of 0.1 mg/day at weekly intervals based on response and tolerability; usual dose range: 0.2 to 0.6 mg/day in 2 divided doses. The manufacturer’s labeling includes a maximum daily dose of 2.4 mg; however, doses >0.6 mg/day are generally not used.
In an alternative attempt to lower the blood pressure, currently used Sevikar might also be replaced with Adapine (nifedipine 30mg) 1# BID and Micardis (telmisartan 80mg) 1# QD.
Minoxidil (not available in stock) can also act as an alternative adjunctive agent. It should be reserved for patients with resistant hypertension who do not respond adequately to an optimized 4-drug regimen, ideally consisting of a thiazide-like diuretic (eg, chlorthalidone) and a mineralocorticoid-receptor antagonist (eg, spironolactone). It can be used in combination with a beta-blocker to prevent reflex tachycardia. Fluid retention may occur and may require additional diuretic therapy (ACC/AHA [Whelton 2018]; Brook 2022). Oral form initial: 5 mg once daily, increase dose gradually in intervals of >= 3 days; usual effective dose: 10 to 40 mg/day in 1 to 3 divided doses; maximum dose: 100 mg/day in 1 to 3 divided doses. During therapy, if supine diastolic pressure is reduced <30 mm Hg, administer total daily dose once daily; if supine diastolic pressure is reduced >30 mm Hg, administer in divided doses (ACC/AHA [Whelton 2018]; manufacturer’s labeling).
{MDS, RAEB-1}
Alprazolam is metabolized by the enzyme CYP3A4 and the antifungal drugs itraconazole, ketoconazole, posaconazole, and voriconazole are strong inhibitors of this enzyme, which can increase the serum concentration of alprazolam.
Each member of the azole class exhibits a unique spectrum of activity, although fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole all demonstrate similar activity against most Candida species. (ref: Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-e50. doi:10.1093/cid/civ933 )
While fluconazole is a less strong (i.e. moderate) CYP3A4 inhibitor than voriconazole, it might be a suitable substitute for voriconazole if no other considerations are taken into account. Additionally, a change from 2# to 1# of alprazolam might also be considered.
On 2022-09-05, blood was drawn about one hour before the time of administration for cyclosporine TDM. It is recommended that blood be drawn within half an hour of the time of administration. As of the latest monitoring result, the level is 193.8 ng/mL, which is generally considered to be within the reasonable range (100 to 400 ng/mL). Based on changes in serum creatinine, renal function appears to be slowly declining (but still within normal range). It might take less time to achieve a concentration greater than 400ng/mL by consecutive daily doses of 200mg than it did in mid-July. A retest is recommended after three days to determine if the dose should be adjusted.
Time serial serum creatinine, cyclosporine trough concentration and cyclosporine daily dose log:
[recommended cyclosporine daily dose to maintain a stable and reasonable trough concentration]
[cyclosporine concentration]
[cyclosporine trough concentration]
[post-transplant immunization
[cyclosporine trough concentration]
As of 2022-07-14, the trough concentration of cyclosporine was 162 ng/mL, which is considered to be an acceptable level.
[Cyclosporine trough concentration follow-up]
[Cyclosporine (ciclosporin) concentration]
[cyclosporine trough concentration]
Dosage of ATG as part of the conditioning regimen in allogeneic PBSCT from matched sibling donors in patients with hematologic malignancies
[assessment, not posted]
[objective]
[assessment]
[assessment]
Patients with acute portal vein thrombosis should be started on low molecular weight heparin to achieve rapid anticoagulation, with a switch to an oral anticoagulant (warfarin or possibly a direct-acting oral anticoagulant [DOAC]) once the patient’s condition has stabilized and no invasive procedures are planned.
Patients with chronic portal vein thrombosis when treated with anticoagulation, enoxaparin is more often used rather than warfarin because of its shorter duration of action, less variability in anticoagulation, decreased need for monitoring, and decreased difficulty when managing patients around the time of liver transplantation. An alternative is to use an oral anticoagulant.
If warfarin is used, goal INR can be set as 2 to 3. (2022-08-03 INR 1.24)
Enoxaparin (in active prescription now) used for venous thromboembolism treatment in patients with active cancer:
Direct oral anticoagulant (DOAC) therapy is an alternative to enoxaparin or warfarin for treating chronic portal vein thrombosis.
Apixaban oral 10 mg twice daily for certain duration followed by 5 mg twice daily.
[assessment]
{Lung cancer at right lower lung, adenocarcinoma, with multiple brain metastasis, cT4N0M1b, stage IV, with mukltiple brain metastasis, PD-L1: TC < 1%, IC < 1%, TPS < 1 %, EGFR E19 deletion and T790M (+)}
[assessment]
[note]
{hypopharynx squamous cell carcinoma, cT3N1M0}
[assessment]
{Rt breast cancer with Rt axillary LNs, lungs, and liver metastases}
[objective]
{DLBCL stage IV}
[assessment]
[assessment]
{oropharyngeal cancer}
{Cholangiocarcinoma, pT4N0cM0, s/p S5 segmentectomy with lymph node dissection and cholecystectomy on 2020-01-13, with T11-12 metastasis and compression fracture s/p radiotherapy to T spine in 2020-04}
[assessment]
[note]
[assessment]
[assessment]
{Right upper lung adenocarcinoma, moderately differentiated with bone metastasis, stage IV}
[assessment]
[assessment]
{ovarian cancer, pT3aN0cM0, FIGO stage IIIA2}
{newly diagnosed with Endometrioid adenocarcinoma T1BN0M0 stage IB s/p Laparoscopic gynecologic oncology staging surgery}
[objective]
[assessment]
{lung adenocarcinoma and esophageal adenocarcinoma}
[Past History]
[note]
[assessment]
{prevent the patient from potential drug interaction: Dasatinib / Inhibitors of the Proton Pump (PPIs and PCABs)}
[assessment]
[assessment]
[note]
{colon cancer with liver mets}
[objective]
{Small Lymphocytic Lymphoma}
[objective]
{left pyriform sinus cancer, cT2N2bMx, stage IVA, brain mets}
{cervical cancer, adenocarcinoma, cT1bN1MB, FIGO stage IIIB}
[BFluid - the amount of electrolyte can be added]
A supplement to my explanation after answering the nurse’s call this morning about the compatibility of B Fluid with KCl.
{Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis}
[note]
[visiting]
Dose adjustment recommendation for the scheduled PBSCT in this impaired renal function patient
[assessment]
{T-cell lymphoma with bone invasion, stage IV}
[note]
The disease should be subtype Peripheral T-cell lymphoma (PTCL), not otherwise specified (NOS)?
T-Cell Lymphomas NCCN EB Version 2.2022 - March 7, 2022, p13
Restage after 3-4 cycles with PET/CT (preferred) or C/A/P CT scan with contrast
Recommended Adult Immunization Schedule — United States, 2012 ( https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm )
[to be discussed]
[assessment]
{pancreatic neck adenocarcinoma,cT1cNXM1, stageIV, with retroperitoneal spread status post Roux-en-Y hepatico-jejunostomy and cholecystectomy}
[objective]
{DLBCL}
[assessment]
{Endometrium neuroendocrine carcinoma, pT2pN0M0, FIGO stage II s/p Staging surgery(ATH + BSO + omentectomy + LN dissection) on 2022/02/14}
[objective]
{Pancreatic adenocarcinoma, T4N1M0, stageIII}
[assessment]
{cholangiocarcinoma, recurrenct, liver and lung mets, s/p colon cancer}
[objective]
{right ovarian cancer, pT1c3N0 if cM0, FIGO IC3 s/p Op on 20200720}
[note]
{intra-hepatic cholangiocarcinoma with lung and right adrenal mets}
[assessment]
[assessment]
{valganciclovir not for herpes}
{pseudomyxoma peritonei}
[assessment]
{CNS DLBCL}
[objective]
[objective]
{alpha-fetoprotein-producing esophageal adenocarcinoma with liver metastasis, T4N2M1 stage IVB}
[memo]
[assessment]
[assessment]
{multiple myeloma}
{gastric cancer with colon mets s/p subtotal gastrectomy and partial T-colectomy}
[subjective]
[objective]
{high grade B-cell lymphoma}
[objective]
{follicular lymphoma}
[assessment]
{steroid conversion}
An approximate corticosteroid dosing conversion
[assessment]
{potential drug interactions}
{tachycardia}
[assessment]
[assessment]
700526699
{drug identification}
Total 14 drugs for identification.
The 10 identified items has been shown as following while the other 4 items still remain unknown:
These drugs will be sent back to ward by the in-hospital porter.
{upper GI bleeding}
[assessment]
{small bowel ileus}
[assessment]
[assessment]
{Vulvar Cancer}
[exam findings]
2023-05-11 CXR
2023-05-02 CXR
2023-04-26 MRA - brain
2023-04-07 CT - abdomen
2023-02-24 Tc-99m MDP bone scan with SPECT
2023-02-22 Skull PA + Lat.
2023-02-02 SONO - chest
2023-01-31 Mammography
2022-12-29 CT - abdomen
2023-03-19, -03-10, -02-05, -01-15, 2022-10-28, -10-25, -09-27, -09-22, -08-22, -06-24 CXR
2022-09-06 CT - abdomen
2022-08-16 Gynecologic ultrasonography
2022-07-05 Laryngoscopy
2022-06-16 Neurosonology
2022-06-16 Brainstem Auditory Evoked Potentials, BAEP
2022-06-15 MRI - brain
2022-06-02 CT - lung/mediastinum/pleura
2022-05-24 Gynecologic ultrasonography
2022-04-08 Chest XR
2022-03-14 Laryngoscopy
2022-03-11 Chest XR
2022-03-01 Gynecologic ultrasonography
2022-02-23 CT - lung/mediastinum/pleura
2022-01-17 Laryngoscopy
2022-01-03 Laryngoscopy
2021-11-06 CT - lung/mediastinum/pleura
2021-10-26 Bronchodilator test
2021-08-09 Tc-99m MDP whole body bone scan
2021-07-19 CT - lung/mediastinum/pleura
2021-04-09 Patho
2021-02-25 Patho
2021-01-29 MRA - Brain
2021-01-13 CT
2020-10-28 Tc-99m MDP whole body bone scan
2020-10-21 CT
2020-07-06 MRI - Brain
2020-07-03 CT
2019-09-18 Patho
2019-09-05 CT: multiple lung nodules, favor metastatic lesions.
2019-06-03 CT: uterine myoma is suspected.
2017-12-13 CT: a 3.0cm tumor at uterus.
2017-11-28 Patho
[consultation]
[surgical operation]
[chemoimmunotherapy]
2023-03-20 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2023-02-22 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2023-02-06 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2023-01-15 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-12-26 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-11-25 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-11-04 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-10-13 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-09-27 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-09-05 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3850mg 46hr
2022-08-22 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2022-07-29 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2022-07-13 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2022-06-28 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2022-06-15 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr
2022-05-30 - irinotecan liposome 70mg/m2 90mg 1.5hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
2022-05-06 - irinotecan liposome 70mg/m2 90mg 1.5hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
XXXX
2021-12-27 ~ undergoing - Onivyde (irinotecan liposome) + FL
2021-04-28 ~ 2021-12-03 - FOLFOX + Bevacizumab
2020-11-24 ~ 2021-04-06 - Nivolumab
2020-10-02 -
2020-07-23 ~ 2020-09-25 - Cisplatin + Vinorelbine, Vinorelbine, take turns alternately
2019-10 ~ 2019-12 - Cisplatin + Paclitaxel
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
Harnalidge (tamsulosin) 0.4mg PO QDAC should be replaced with Urief (silodosin) 8mg PO QD as a preferred alternative.
[assessment]
{mediastinum small cell carcinoma with pericardial effusion with SVC syndrome, stage IV}
[objective]
[assessment]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
{ovarian clear cell carcinoma stage IA}
[objective]
[objective]
[assessment]
[objective]
[objective]
[assessment]
[objective]
This 43 years old female patient has the history of: 1) Chronic kidney disease for 10 years; 2) Ulcerative colitis with medical treatment for 20 years; 3) Fourth degree hemorrhoids status post hemorrhoidectomy on 20210623; 4) Left arteriovenous fistula on 20220124.
diagnosis
exam finding
lab data
surgical operation
[assessment]
This patient has CKD stage 5 adminitted on 2022-04-29
CKD stage 5, high Creatinine, high BUN, high phosphorus, low calcium, low bicarbonate normal CRP and WBC AV shunt
[objective]
{synchronous double (breast and colon) primary tumors s/p MRM s/p hemicolectomy}
[objective]
[assessment]
[objective]
{esophageal squamous cell carcinoma with liver and lung mets}
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
{ovarian cancer}
[objective]
[tube feeding]
{Recurrent hepatocellular carcinoma with Lung and C-spine, T-spine and L-spine metastasis cT2N0M1 stage IV}
[objective]
[assessment]
{Acute myeloid leukemia}
[objective]
[Quinolones-Antacids Interactions]
objective
assessment
suggestion
[Interprofessional Practice Meeting and Family Meeting]
[mesna administration]
[objective]
Creatinine lab data: - 2022-01-10 1.25mg/dL - 2022-01-07 1.43mg/dL - 2022-01-03 0.93mg/dL
[assessment]
[suggestion]
[objective]
[reference]
[assessment]
{Left renal cell carcinoma with metastatic mediastinal lymphadenopathies and suspecious RUL lung metastasis, liver and bone metastases s/p chemotherapy and radiotherapy}
[objective]
{Recurrence nasopharyngeal carcinoma with skull base destruction and cranial nerve (V2, VI) invasion , liver metastasis and multiple lung metastases in progression.yT4N2M1,stageIVB}
[objective]
[assessment]
{rectal cancer with liver mets s/p LAR and liver partial resection}
[objective]
exam finding
lab data
surgical operation
chemoimmunotherapy
[assessment]
{Acute myeloblastic leukemia, not having achieved remission}
[objective]
[compatibility]
The combination of calcium gluconate, magnesium sulfate, and potassium chloride in 0.9% sodium chloride normal saline is compatible.
Lab data reported on 2022-01-10
Danol (Danazol) androgen is prescribed to pause menses to maintain RBC, HGB levels in the setting of chemotherapy.
{rectal cancer cT2N1bM0 stage IIIA}
[subjective]
[objective]
[initial presentation]
[definite diagnosis]
[disease extent]
[treatment & plan]
[effect & side effect]
[ongoing problem]
[assessment]
{hepatic failure, cirrhosis of liver, hepatorenal syndrome, esophageal varices, gastric varices, ascites, type 2 diabetes ellitus, hyperlipidemia, anemia}
[objective]
[assessment]
{ovary cancer s/p oophrocystectomy}
[objective]
[assessment]
[objective]
[assessment]
[objective]
[objective]
[assessment]
[objective]
[assessment]
{hypopharyngeal and supraglottic cancer, cT4bN2b cM0, stage IV with recurrent lung mets, progression of mets pulmonary lesions and mediastinal/hilar LAP}
[objective]
[assessment]
[objective]
[assessment]
{Malignant neoplasm of rectosigmoid junction, stage cT3N0M0, stage IIA}
[objective]
[objective]
[assessment]